Construction of a Simulation Scenario and a Low-Cost Simulator for Teaching Thoracentesis Surgical Technique: A Validation Study

Construction of a Simulation Scenario and a Low-Cost Simulator for Teaching Thoracentesis Surgical Technique: A Validation 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 Construction of a Simulation Scenario and a Low-Cost Simulator for Teaching Thoracentesis Surgical Technique: A Validation Study Roberson Antequera Moron, Victor Cardozo, Marcos Antonio Marton Filho, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3796982/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 01 Jul, 2025 Read the published version in BMC Medical Education → Version 1 posted 4 You are reading this latest preprint version Abstract Background Thoracentesis yields valuable insights in pleural effusion diagnosis by accurately interpreting pleural fluid analysis results and can cause several complications, which emphasizes the importance of training in a simulated environment. There are many expensive simulators related to this procedure and few validated scenarios. This study aimed to build and validate a low-cost simulator and a clinical simulation scenario for teaching the thoracentesis surgical technique to undergraduate medical students. Methods This is a methodological study carried out at a public university in the interior of the state of São Paulo, Brazil. It was carried out in three methodological stages, namely: 1) Construction of the simulator, which involved planning, surveying, pricing, and use of material resources 2) Construction of a simulated thoracentesis scenario, based on literature and a simulation script and 3) Validation by experts and pilot study of the simulator and scenario. Experts were selected according to Fehring criteria. Results The simulator proved to be suitable and low-cost (US $ 18). Modifications to the scenario were suggested by the experts and students in the pilot study, with 100.0% agreement. Conclusions In conclusion, a low-tech, handmade, and low-cost simulator was built and validated for training in the thoracentesis surgical technique, as well as a clinical simulation scenario for the management of patients with pleural effusion, which can be included in various medical teaching contexts. Simulation Training Validation Study Low-Cost Technology Thoracic Surgical Procedures Cost Undergraduate Figures Figure 1 Figure 2 Figure 3 Introduction Throughout the history of surgical education, new challenges, such as a steep learning curve for minimally invasive surgery, and the stronger ethical implications of learning on patients, have made the traditional logic of " See one, Do one, Teach one " more problematic [ 1 ]. Studies show that only half of newly graduated doctors believed they received adequate exposure upon completing their surgical training [ 2 , 3 , 4 ]. In this context, relevant discussions – such as the European Working Time Directive [ 5 ] – have been tensioned to question the traditional quality, quantity, and need for training in surgical education. From this perspective, there has been much discussion about the issues that justify the creation and implementation of structured surgical training programs in undergraduate curricula [ 6 ]. When considering the characteristics of the current world of work, ethical issues, and bioethics, training institutions must invest in well-qualified human resources, based on teaching and learning methods and resources that are compatible with the health needs of the population. Among ethically accepted teaching and learning methods is clinical simulation [ 7 ]. Most simulation-based initiatives achieve a reasonable improvement in learner skills and confidence. In surgical education, simulation-based learning is an important step towards training a safer and more efficient generation of surgeons [ 8 ]. Optimizing these efforts can be accelerated by developing simulators for basic surgical training at the undergraduate level [ 9 ]. Current evidence shows that incorporating the use of animal tissue or other simulation methods into undergraduate educational programs can be a catalyst for advancing surgical education [ 10 ]. Simulators, regardless of whether they use animal tissue ( wet lab ), non-animal devices ( dry lab ), or even corpses, allow for different levels of fidelity that can be adjusted to the expectations of surgical teaching. Lower-fidelity, low-cost modules would be aimed at basic surgical training, while higher-fidelity, high-cost modules can be reserved for teaching more advanced students [ 10 , 11 ]. When simulators are associated with surgical environment contexts and issues involving decision-making, they can significantly improve the quality of care provided [ 12 ]. Many skills and competencies can be developed in surgery in the context of undergraduate medical education. However, in various realities, especially in the Latin American context, these possibilities are limited by issues that involve investments in teacher training, the acquisition of simulators of different technological levels, and the acquisition and/or development of instruments and other technologies. These limitations can contribute to widening inequalities in health training and the tendency to use traditional teaching and learning methods [ 13 ]. Among the various skills required by a surgeon and general practitioners in general, given their frequency in practice and clinical relevance to the patient's prognosis, is thoracentesis. Thoracentesis is a procedure that aims to remove fluid or air from the pleural space, usually with a needle, for diagnosis or relief of respiratory symptoms [ 14 ]. Thoracentesis can cause several complications, which emphasizes the importance of training in a simulated environment. The main complications of thoracentesis include pneumothorax, hemothorax due to injury to intercostal vessels, re-expansion edema, pain at the puncture site, empyema, soft tissue infection, and accidental puncture of abdominal viscera such as the liver and spleen. Pneumothorax is the most common complication, occurring in up to 20% of cases, related to medical inexperience, large-gauge needles, excessive extraction of pleural fluid, multiple punctures, chronic obstructive pulmonary disease, repeated thoracenteses, and pleural loculations. Despite this, thoracentesis is considered a less invasive procedure and is the method of choice for obtaining pleural fluid samples, to improve the chance of diagnosis and minimize risks [ 15 ]. Clinical simulation can be a viable and reliable strategy for learners to achieve competencies and skills in the subject. In a simulated clinical environment, curricula with simulated thoracentesis practice increased residents' skills, appreciation of training, evaluation, and feedback [ 16 ]. At its most relevant degree of impact on practice [ 17 ], evidence shows that prior thoracentesis training of residents improves patient care outcomes [ 18 ]. Therefore, recognizing the benefits of clinical simulation for teaching this technique justifies its inclusion in curricula and simulation programs. Studies available in the literature have already presented simulator and simulation models for teaching and training the thoracentesis technique, mainly focusing on newly qualified doctors [ 19 , 20 , 21 ]. However, developing and sharing different educational technologies contributes to their widespread dissemination and reproducibility in different teaching and learning contexts. In this context, this study aimed to build and validate a low-cost simulator and a clinical simulation scenario for teaching the thoracentesis surgical technique to undergraduate medical students. Material and Methods This is a methodological study carried out at a public university in the interior of the state of São Paulo, Brazil. Methodological research involves three processes, namely technology development, production, and construction Polit and Beck (2011) [ 22 ]. The methodological steps of this study are presented in three stages, namely: Stage 1 - Development and construction of a low-cost simulator To develop and build the low-cost simulator, the research team asked the following question: What attributes are needed to build a low-cost simulator for teaching the thoracentesis surgical technique? Realism: the simulator should provide an experience that can reproduce thoracentesis and pleural drainage procedures as realistically as possible, taking into account the correct techniques for carrying them out, as well as tactile and visual sensory experiences. Reproducibility: the simulator should allow for multiple uses and easy replacement of disposable parts once it has reached its useful life. Low cost: the simulator should have lower production and maintenance costs than those quoted for prefabricated simulators available for the same purpose. After defining the attributes, a search was made for materials in the local trade (Table 1 ) and a prototype drawing of the simulator's structure was made (Fig. 1 ). Table 1 . Researched material resources that were justified according to the established criteria, Bauru, 2023. Figure 1 . Schematic model of the simulator, Bauru, 2023. Stage 2 - Building the clinical simulation scenario. To build the clinical simulation scenario, we used the criteria of Fabri et al (2017) [ 23 ], which consider the following structuring elements: the student's prior knowledge; learning objective; theoretical basis of the activity; preparation of the scenario; and evaluation. Initially, intending to encourage discussion about its construction, the research team started with the following inquiry: “What information, based on the structuring elements adopted, is essential for the construction of a pleural effusion clinical simulation scenario with an indication for thoracentesis?” Two specialists in clinical simulation and two medical-surgical lecturers took part in its development. The scenario included patient care in the environment of an emergency care unit. It took into account the cognitive, affective, and psychomotor domains [ 24 ] and was based on evidence [ 15 , 25 , 26 , 27 , 28 , 29 , 30 , 31 ]. Stage 3 - Clinical simulation scenario validation processes Face and content validation The criteria proposed by Fehring (1987) [ 32 ] were used to select the experts, with a minimum score of five points out of a total of 14: master's degree (4 points), master's dissertation in the area of interest of the study (1 point), doctoral thesis in the area of interest of the study (2 points), clinical practice with one year or more of experience in the subject of the study (1 point), specialization in the subject of interest of the study (2 points), publication of relevant research in the area of interest of the study (2 points) and publication of an article in the area of interest of the study in reference journals (2 points). In this study, the area of interest was clinical simulation and the topic of interest was surgical medicine. Three judges took part (100.0%) [ 32 ]. Next, to organize the final material, the Delphi Technique was used, which consists of a systematized method for judging information, aimed at obtaining a consensus from experts and users on a given topic, employing validations articulated in phases or cycles. The judges summarize, point out improvements, and consider the material examined in all its dimensions [ 33 ]. To assess the consensus between the judges, as well as the degree of agreement between them, the Content Validity Index (CVI) was used, where each item was assessed separately, followed by the instrument as a whole. To do this, two Likert scales were used with a score of one to five, where four and five corresponded to positive responses, three to neutrality, and two and one to negative responses. The instrument's index score was calculated using the Content Validity Index (CVI). A minimum value of 80% was set for both the CVI and the agreement index [ 33 ]. Pilot study To adapt the technologies built (simulator and simulated scenario), a pilot test was carried out with undergraduate medical students regularly enrolled in the 4th semester of the course. The students were invited online by a student researcher. The first ten students enrolled were included in the pilot. The pilot followed the classic cycle of simulated practice which consisted of skills training, scenario development, feedback, debriefing, and evaluation. Before the skills training and scenario development, the students took part in a dialogue lecture on the subject. They then took part in group skills training, followed by a simulated scenario, debriefing, and feedback. After the simulated practices, the students, in a meeting with the researchers, expressed their opinions on the simulator developed in this research, on the simulation scenario and suggested improvements to the practices offered. The pilot test was carried out in the skills and simulation laboratory at the researchers' institution. Analysis and presentation of results The results were presented in the form of tables, figures, and a discursive report. After the final analysis of the expert evaluations and the pilot project, the final version of the products was produced. Ethical aspects This study was submitted to the Research Ethics Committee of the Bauru School of Dentistry and was approved under numbers 5.072.385 and 5.294.181. Acceptance to participate in the study was formalized by signing the informed consent form. As this study presents some qualitative aspects of the feedback approach, the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist was followed. [ 34 ]. Results Building the low-cost simulator To better analyze the results and have enough training material available for the students, five simulators for thoracentesis training were built identically. The estimated cost of each simulator was 18 US $ . To make the simulators easier to make and to reduce the cost of acquisition and maintenance, plastic mannequins used in the fashion retail market were used. The back of the mannequins was cut with a mini-drill saw→ to allow access to the inside. Next, the place where the underarm side wall would be drilled was marked to allow the ribs to be placed. The sealing gasket made from ethylene-vinyl acetate (EVA) was used as a marker at the height of the nipple line. The seal was obtained by interposing EVA and acrylic seals with 4 holes for the screws to pass through. Laser cutting was used to ensure the accuracy of the EVA and acrylic cuts. The walls of the sealing gasket and the fixing acrylic were 2 cm wide and 3 mm thick. The rectangular acrylic joint to allow the ribs to be fitted was made to measure 16.5 X 9 cm. The pork skins and ribs used were cut using the same acrylic plate as a size mould. The mannequin parts were stored in a freezer (temperature − 3 o C) and were only assembled on the day of the skills training and development of the simulated scenario, to avoid degradation of the biological components. To faithfully mimic the sensation of puncturing the pleural space, we used pork ribs bought from a supermarket. The ribs were cut and perforated, while still frozen, to the same size as the mannequin's "window", respecting the same direction of inclination as the human ribs. In addition, pork skin of the same size was boiled in water at 100 degrees for 10 minutes to soften it and improve the feel of human skin. The skin was also perforated at 4 points for fixation. Internally, the "pleural space" was constructed using a collagen deli bag, with its upper end open, making it possible to change the contents without disassembling the whole simulator each time it was used. Vacuum-sealed plastic bags with liquids inside were placed inside the bag. The assembly was fixed to the wall with two acrylic plates (inner and outer) fixed with screws and nuts with threaded knobs. The EVA sealing gasket was cut to the same shape as the window to ensure the necessary seal during punching. The pressure of the screws on the acrylic, the EVA, the collagen, the wall of the mannequin, the rib, and the skin provided the necessary seal to prevent leaks during the punctures. Figure 2 . Assembly of the simulator, Bauru, 2023. The simulators developed were placed on a surgical table with the fields and materials needed to practice the thoracentesis surgical technique. The students had the opportunity to train their skills, take part in a clinical simulation scenario, and evaluate the technologies developed. Figure 3 . Assembled simulators, Bauru, 2023. Face and content validation by experts and the pilot study The validation of the thoracentesis scenario and simulator was carried out with the collaboration of three judges who had the following sociodemographic characteristics: specialization in general surgery (66.6%) and thoracic surgery (66.6%), with an average time working in the area of 17.6 years (minimum of 10 years and maximum of 30 years), with a doctorate (66.6%), experience in clinical simulation (100.0%) and scientific production in the area of surgery and simulation (100.0%). Regarding the simulator, there was 100% agreement between the experts in the first evaluation process. Concerning the proposed scenario, adjustments were made and, after the second round of evaluation, there was 100% agreement on all the items in the scenario. Table 2 shows the items modified in the scenario. Table 2 Items assessed and suitable for the proposed simulated clinical scenario, Bauru, 2023. Items assessed Round 1 Round 2 Modified items CVI CVI Primary objective 100.0% 100.0% - Secondary objectives 80.0% 100.0% Adjusting verbs, withdrawal of inspection, palpation and percussion. Target audience 100.0% 100.0% - Theoretical foundation 100.0% 100.0% - Material resources 100.0% 100.0% - Actor and simulator characterization 100.0% 100.0% - Clinical case 60.0% 100.0% Taken from the physical examination inspection, palpation and percussion Complementary tests 70.0% 100.0% Printed complementary tests introduced (X-ray and full blood count), given to the student when requested. Leukocytosis, replaced by leukocytosis with left shift. Student case description 100.0% 100.0% - Evaluation 90.0% 100.0% Objective Structured Assessment of Technical Skill (OSAT) included The pilot study consisted of skills training and scenario development. It took place in the clinical simulation laboratory and was complemented by debriefing, feedback, and student evaluation. Ten 4th year undergraduate medical students took part in this stage of the pilot study. Among the students, five (50.0%) were female, and five (50.0%) were male; six (60.0%) reported that they carried out training in the skills and simulation laboratory voluntarily and as a complement to their undergraduate activities. The students considered the clinical case to be well formulated. However, they pointed out that there was too much information, indicating that this could jeopardize the execution of the tasks set out in the scenario. They therefore suggested improvements in clarifying the clinical case, the inclusion of printed exams, and greater objectivity in the information and instructions on the tasks to be carried out. Table 3 shows the clinical simulation scenario in its final version, after the inclusions and exclusions suggested by the judges and students. Table 3. Scenario of patients with pleural effusion, according to the criteria proposed by Fabri et al (2019). Discussion The teaching of medical skills, especially surgical procedures such as chest drainage, faces significant challenges in a context where the need to balance practical training with patient and health professional safety is a pressing issue. To this purpose, the adoption of teaching methods that promote technical competence without exposing patients to unnecessary risks becomes crucial [ 36 ]. Clinical simulation is a teaching method that takes patient safety into account [ 37 ]. Well-structured simulated practice activities have an impact on student motivation [ 38 ] and enable not only the acquisition of diagnostic and therapeutic skills but also the development of competencies such as decision-making, teamwork, and effective communication [ 12 ]. The resources for clinical simulation sessions include simulators. Simulators are technologies designed to reproduce and/or represent a device, body part, or service [ 37 ]. Simulators and simulated patients contribute to the emotional preparation of students, as they allow them to practice their skills in planned activities, allowing feelings such as anxiety and stress to be worked through, as well as enabling better learning to be achieved [ 39 ]. In general, low-cost simulators are usually developed using alternative materials that are easy to acquire and cost less than the reference models available on the market [ 40 , 41 , 42 , 43 , 44 , 45 ]. The literature does not determine that more realistic simulators contribute more to learning than a low-fidelity simulator [ 46 , 47 , 48 ] what determines the resource to be used is always the learning objective of the activity [ 48 ]. Therefore, depending on the learning objectives set, the use of low-cost simulators can guarantee the effectiveness of simulation in the context of the teaching and learning process [ 44 , 49 , 50 , 51 ]. Low-cost simulators, although less sophisticated in terms of technology when compared to robotic simulators, are capable of providing significant learning experiences when incorporated into simulated scenario contexts, allowing procedures to be repeated and errors to be corrected in a controlled environment and without risk to real patients, at a low cost to educational institutions [ 50 ]. From a conceptual point of view, low-cost simulators have essential attributes, namely: cost, accessibility, technologies, manufacture and reproducibility, realism, versatility, and usability. In this study, the simulator was built based on three of these: realism, reproducibility, and cost. As such, the simulator built has three fundamental characteristics: low-tech, handmade, and low-cost. It is classified as low-tech because it does not have technological resources such as electrical and electronic devices, software, or advanced technology. It can also be assembled intuitively. It was produced by hand, i.e. in a non-industrial environment, with hand tools and accessible materials, and in low demand. Finally, the low cost, given that industrial simulators for the same purpose cost much more than the one produced by the research team. The simulator that has been built enables training in thoracentesis surgical skills. It was well evaluated by experts and students in the pilot project. It can also be reproduced for use in other procedures such as cystostomy, paracentesis, and jugular puncture, among many others, and can also be used for training and assessing professionals. In addition to the industrial materials used to build the simulator in the report, the authors chose to include animal tissue (pig skin and ribs). However, these materials can be replaced with synthetic skin, easily made from silicone rubber. Other studies have also reported on the use of fruit, meat, and animal tissue as an alternative to increasing the realism of simulated training [ 41 , 53 , 54 ]. A study carried out in 2019 in Brazil presented the construction of two simulators: one for venous access and one for renal biopsy. The simulators were built with chicken breast, Penrose drain, plastic straw, and pig kidney. The authors report that the simulators allowed immediate identification of anatomical structures of interest and enabled the development of skills needed to perform invasive procedures [ 53 ]. Another Brazilian study developed a training model using tomatoes to acquire ophthalmological microsurgical skills. The models developed proved to be viable for training microsurgical dissection [ 54 ]. A study, also carried out in Brazil, developed a low-cost simulator for teaching the repair of obstetric anal sphincter injuries. In addition to other materials, beef was used. The simulator allowed participants to improve their knowledge of anatomy and physiology, and to develop surgical competencies and skills [ 41 ]. It's important to note that the literature points to a tendency to classify simulators that use biological materials as handmade simulators. However, the authors of this article believe that "handmade" refers to the production method. In this way, low-cost simulators can be produced in an artisanal, industrial, or mixed way. Artisanal simulators are developed and produced in a non-industrial environment, using manual and/or mechanical equipment and tools, with alternative and accessible materials, produced to specific demands, on a low scale, or an experimental basis. It's also worth pointing out that, in terms of cost, considering the characteristics of perishable foods and the need for continuous replacement, simulators that use prime meats can have a high cost. Furthermore, low or high cost can have different connotations. A "low cost" in developed countries can be considered a "high cost" in developing or underdeveloped countries [ 44 , 45 ]. In this study, the simulator had a final cost of 18 US dollars, characterizing it as low-cost, given that similar models available in the simulator industry cost between 1,600 and 3,000 dollars. A similar simulator, developed in the city of Fortaleza, Brazil, cost US $ 21.00. In addition, the results point to its easy reproducibility and usefulness for teaching chest drainage [ 55 ]. A study carried out in southern Brazil with 49 medical students compared student safety in the closed chest drainage procedure in a low-cost model (synthetic, 3D printed) with an animal model (pork ribs). Although a higher score was observed in the synthetic model group for learning the chest drainage technique when compared to the animal model group, there was no statistical significance between the groups. There was a preference for the 3D model. The cost of the simulator developed was also lower than those available on the market [ 56 ]. Judges with expertise in surgery validated the clinical simulation scenario. In the first round of evaluation, only four criteria did not obtain a CVI of 100.0%. Therefore, the researchers decided to make the adjustments shown in Table 1 and send the scenario for another round of evaluation. After two rounds of evaluation, all the items reached 100.0% agreement. In addition, the scenario was also evaluated by students in a pilot study, adding clarification and complementary resources. A clinical simulation scenario is an extremely important tool for planning, conducting, and evaluating simulated clinical experiences. A well-structured scenario with clear learning objectives can result in meaningful experience and learning [ 23 , 57 , 58 , 59 ]. To this end, as presented in the results found and suggested by the experts, they should be constructed with clear language and incorporate significant data into their execution. The use of technologies such as the low-cost simulator and the scenario validated in this study can be considered a relevant cost-effective strategy for training healthcare professionals and, as highlighted in this research, future doctors. Conclusions A low-tech, handmade, low-cost simulator was built and validated for training in the surgical technique of thoracentesis and a clinical simulation scenario for managing patients with pleural effusion. Although this study has some limitations, such as the small number of judges and the lack of evaluation of the simulator's usability, which will be carried out in a later study, it was noted that the simulator had a much lower final cost than other models available in the industry. The desired realism was achieved in that it allowed thoracentesis and pleural drainage techniques to be carried out with sensory and visual characteristics that were very close to reality. Furthermore, the simulator parts can be built and replaced after multiple uses. Therefore, it can be reproduced easily with few resources. In this study, the simulator built and the scenario presented were validated and considered suitable by experts in the field. They were also considered suitable by users (students). We therefore encourage the incorporation of these teaching resources, as well as future studies that can further expand the understanding of the impacts of their use and the learning of clinical skills. Abbreviations EVA Ethylene-vinyl acetate CVI Content Validity Index Declarations Acknowledgments RAM thanks to Gabriel Araújo Medeiros and Jan Beatriz Felinto de Santana for providing writing and image editing services, and to the University of São Paulo for providing their locations. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. The authors alone are responsible for the content and writing of this article. Authors' information Roberson Antequera Moron https://orcid.org/0000-0003-1115-7276 Victor Cardozo https://orcid.org/0009-0008-7301-7934 Marcos Antonio Marton Filho https://orcid.org/0000-0003-0234-1258 Alessandra Mazzo https://orcid.org/0000-0001-5074-8939 Raphael Ranieri de Oliveira Costa https://orcid.org/0000-0002-2550-4155 Carlos Ferreira dos Santos https://orcid.org/0000-0002-0405-3500 Authors and Affiliations Bauru School of Dentistry (FOB) and Craniofacial Anomalies Rehabilitation Hospital (HRAC), University of São Paulo, São Paulo, Brazil. Roberson Antequera Moron Bauru Medical School, Department of Pediatric Dentistry, Orthodontics, and Public Health, Bauru School of Dentistry, University of São Paulo, Bauru, Sao Paulo, Brazil. Victor Cardozo, Marcos Antonio Marton Filho, Alessandra Mazzo Medicine Course, Federal University of Rio Grande do Norte (UFRN), Caicó, Rio Grande do Norte, Brazil. Raphael Ranieri de Oliveira Costa Bauru School of Dentistry (FOB) and Craniofacial Anomalies Rehabilitation Hospital (HRAC), University of São Paulo, São Paulo, Brazil. Carlos Ferreira dos Santos Authors' contributions RAM made the idealization and conducted all the stages of the study. VC and MAMF participated in stages 2 and 3, RAM elaborated the clinical case, CFS and AM were supervisioners during all the study. RAM wrote the main manuscript. RAM, RROC and AM made the final revision and writing corrections to the paper. Ethics approval and consent to participate This study was performed in accordance with the declarations of Helsinki, under approval of the Research Ethics Committee of the Bauru Dental School of the University of Sao Paulo (CAAE 5.072.385 and 5.294.181). 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Marques JBV, Freitas D, Método. Pro-posições. 2018;29(2):389–415. https://doi.org/10.1590/1980-6248-2015-0140 . DELPHI: caracterização e potencialidades na pesquisa em Educação. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19:349–57. https://doi.org/10.1093/intqhc/mzm042 . Campos MEC, Oliveira MMRD, Assis LBD, Reis AB, Gonçalves FB. Validation of the Objective Structured Assessment of Technical Skill in Brasil. Revista da Associação Médica Brasileira. 2020;66(3):328–33. https://doi.org/10.1590/1806-9282.66.3.328 . Vilella DS, Leite LM, Nassar MED. A simulação realística como estratégia de ensino em atendimentos pré-hospitalar: um relato de experiência de resultados. São Paulo: Secretaria da Saúde, 2010. 1 p. ilus. Available at: Coleciona SUS, COGERH-Produção, Sec. Munic. Saúde SP, SAMU-Produção, Sec. Munic. Saúde SP, Sec. Munic. Saúde SP. ID: biblio-937129. Accessed 20 Oct 2023. Costa RRO, Medeiros SM, Martins JCA, Coutinho VRD, Araújo MS. Effectiveness of simulation in teaching immunization in nursing: a randomized clinical trial. Rev Latinoam Enferm. 2020;28. https://doi.org/10.1590/1518-8345.3147.3305 . Sanches BC, Almeida RGS, Lourençone LFM, Costa RRO, Mazzo A. Laboratório de habilidades e simulação: perspectivas atuais e futuras. Revista Latinoam de Simulación Clínica. 2022;4:106–11. https://dx.doi.org/10.35366/109711 . Teixeira CRDS, Pereira MCA, Kusumota L, Gaioso VP, Mello CLD, Carvalho ECD. Avaliação dos estudantes de enfermagem sobre a aprendizagem com a simulação clínica. Revista Brasileira de Enfermagem. 2015;68(2):311–9. https://doi.org/10.1590/0034-7167.2015680218i . Medeiros GA, Gualberto IJN, da Silva CHND, et al. Development of a low-cost congenital abdominal wall defect simulator (wall-go) for undergraduate medical education: a validation study. BMC Med Educ. 2023;23(1):1–10. https://doi.org/10.1186/s12909-023-04929-3 . Knobel R, Volpato LK, Gervasi LC, Viergutz RA, Trapani Júnior AA, Simple. Reproducible and Low-cost Simulator for Teaching Surgical Techniques to Repair Obstetric Anal Sphincter Injuries. Rev Bras Ginecol Obstet. 2018;40(8):465–70. https://doi.org/10.1055/s-0038-1668527 . Souza FX, Rodrigues JC, Andrade JD, Oliveira CM, Barbosa AL, Brandão AD. Modelo simulador de baixo custo para treinamento de septoplastia. Revista Eletrônica Acervo Saúde. 2020;42e2827–7. https://doi.org/10.25248/reas.e2827.2020 . Knobel R, Menezes MO, Santos DS, Takemoto MLS. Planning, construction and use of handmade simulators to enhance the teaching and learning in Obstetrics. Rev Latinoam Enferm. 2020;28. https://doi.org/10.1590/1518-8345.3684.3302 . Knobel R, Costa RRO. Confecção e uso de simuladores de baixo custo: experiências da Medicina e Enfermagem. In: Gerson Alves Pereira Junior; Hermila Tavares Vilar Guedes. (Org.). Simulação em saúde para ensino e avaliação: conceitos e práticas. 1ed. São Carlos - SP: Cubo Multimídia. 2021;8:119–127. Knobel R, Costa RRO. Construção e uso de simuladores de baixo custo. In: Gustavo Salata Romão; Marcos Felipe Silva de Sá; César Eduardo Fernandes; Agnaldo Lopes da Silva Filho. (Org.). Residência médica: ensino e avaliação de competências. 1ed. São Paulo - SP: Editora Manole, 2022;1:214–224. DeStefano CC, et al. A randomized controlled trial of birth simulation for medical students. Am J Obstet Gynecol [S l]. 2015;213(1):91. https://doi.org/10.1016/j.ajog.2015.03.024 . .e1-91.e7 . Schaumberg A, Schröder T, Sander M. Notfallmedizinische Ausbildung durch Simulation. Anaesthesist. 2017;3(66):189–94. https://doi.org/10.1007/s00101-017-0264-x . Costa RRO, Mata ANS, Almeida RGS, Coutinho VRD, Alves LYM, Mazzo A. Skills and clinical simulation laboratory in times Covid-19: possibilities and practical recommendations. MEDICINA (RIBEIRAO PRETO. ONLINE). 2021;54:e-177075. https://doi.org/10.11606/issn.2176-7262.rmrp.2021.177075 . Rowse PG, Ruparel RK, Brahmbhatt RD, Dy BM, AlJamal YN, Abdelsattar J, Farley DR. Assimilating endocrine anatomy through simulation: a pre-emptive strike! Am J Surg. 2015;209(3):542–6. https://doi.org/10.1016/j.amjsurg.2014.12.004 . Magee SR, Shields R, Nothnagle M. Low Cost, High Yield: Simulation of Obstetric Emergencies for Family Medicine Training. Teach Learn Med. 2013;25:207–10. https://doi.org/10.1080/10401334.2013.797353 . Ramseyer AM, Lutgendorf MA. Implementation of Low-Cost Obstetric Hemorrhage Simulation Training Models for Resident Education. Mil Med. 2019;184:11–2. https://doi.org/10.1093/milmed/usz098 . SOCIETY FOR SIMULATION IN HEALTHCARE. Dictionary of Healthcare Simulation. https://www.ssih.org/dictionary . Accessed in: 22 Nov 2023. Tramontin DF, Teixeira RKC, Santos DR dos, de Araújo NP, Costa LVP da, Calvo FC et al. Se a vida lhe der tomates, treine microcirurgia. Rev brasoftalmol [Internet]. 2020;79(6):363–365. https://doi.org/10.5935/0034-7280.20200079 . Bastos, et al. Utilização de simuladores artesanais no treinamento ultrassonográfico de procedimentos invasivos em nefrologia: acesso venoso e biópsia renal. Braz J Nephrol (J Bras Nefrol). 2019;41(3):423–6. https://doi.org/10.1590/2175-8239-JBN-2018-0211 . Oliveira MA, Queiroz EF, Mesquita DAK, Marques LM, Maia FM, Correa RV. Desenvolvendo um modelo sintético de baixo custo para treinamento de drenagem torácica em ambiente de simulação. Revista De Medicina. 2020;99(2):115–21. https://doi.org/10.11606/issn.1679-9836.v99i2p115-121 . Bettega AL, Brunello LFS, Nazar GA, De-Luca GYE, Sarquis LM, de Wiederkehr H. Rev Col Bras Cir [Internet]. 2019;46(1):e2011. https://doi.org/10.1590/0100-6991e-20192011 . A, et al. Simulador de dreno de tórax: desenvolvimento de modelo de baixo custo para capacitação de médicos e estudantes de medicina.. Negri EC, Pereira Júnior GA, Cotta Filho CK, Franzon JC, Mazzo A. Construction and validation of simulated scenario for nursing care to colostomy patients. Texto contexto-enferm. 2019;28:e20180199. https://doi.org/10.1590/1980-265x-tce-2018-019 . Carreiro BO, Romão LGB, Costa RRO. Construção e validação de cenários de simulação de Suporte Básico de Vida na Atenção Básica:. O Mundo Da Saúde. 2021; 45 (s/n):195–209. https://doi.org/10.15343/0104-7809.202145195209 . Costa RRO, Romão LGB, Araújo Júnior JS, Araújo ASPR, Carreiro BO. Med (Ribeirão Preto) [Internet]. 2022;55(3):e–192299. https://doi.org/10.11606/issn.2176-7262.rmrp.2022.192299 . Construção e validação de cenário de simulação médica no ensino de imunização. Tables Table 1 and 3 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Table1.docx Table 1. Researched and justified material resources according to the established criteria, Bauru, 2023. Table3.docx Table 3. Scenario of patients with pleural effusion, according to the criteria proposed by Fabri et al (2019). Cite Share Download PDF Status: Published Journal Publication published 01 Jul, 2025 Read the published version in BMC Medical Education → Version 1 posted Editorial decision: Revision requested 04 Jun, 2024 Editor assigned by journal 04 Jun, 2024 Submission checks completed at journal 23 Dec, 2023 First submitted to journal 23 Dec, 2023 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3796982","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":262779410,"identity":"aaf984ec-d9ca-4a81-adc2-ddb0111424c6","order_by":0,"name":"Roberson Antequera 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14:11:38","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":114931,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAssembly of the simulator, Bauru, 2023.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-3796982/v1/50ff652691477957b169d0a1.jpeg"},{"id":48971709,"identity":"1abf4265-4782-4a52-a4f6-e86789256c10","added_by":"auto","created_at":"2023-12-29 14:19:38","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":85589,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAssembled simulators, Bauru, 2023.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-3796982/v1/84935bb4797ff009ac23196f.jpeg"},{"id":86179167,"identity":"afa077c7-d675-40c4-9ac1-257ef702e9cc","added_by":"auto","created_at":"2025-07-07 16:16:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1227539,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3796982/v1/0f9f990d-0058-456b-b498-7bea25bbb7ac.pdf"},{"id":48971289,"identity":"02235ef1-79a8-4455-930b-02c40ff8a4a0","added_by":"auto","created_at":"2023-12-29 14:11:39","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":174376,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eTable 1. Researched and justified material resources according to the established criteria, Bauru, 2023.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Table1.docx","url":"https://assets-eu.researchsquare.com/files/rs-3796982/v1/54e7d70494bcd6446490fadb.docx"},{"id":48971290,"identity":"7e5f4d5c-9eb6-4865-9153-09f790645d94","added_by":"auto","created_at":"2023-12-29 14:11:39","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":93717,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eTable 3. Scenario of patients with pleural effusion, according to the criteria proposed by Fabri et al (2019).\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Table3.docx","url":"https://assets-eu.researchsquare.com/files/rs-3796982/v1/1a52239d1e357ef7a4a3da86.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eConstruction of a Simulation Scenario and a Low-Cost Simulator for Teaching Thoracentesis Surgical Technique: A Validation Study\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThroughout the history of surgical education, new challenges, such as a steep learning curve for minimally invasive surgery, and the stronger ethical implications of learning on patients, have made the traditional logic of \"\u003cem\u003eSee one, Do one, Teach one\u003c/em\u003e\" more problematic [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Studies show that only half of newly graduated doctors believed they received adequate exposure upon completing their surgical training [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn this context, relevant discussions \u0026ndash; such as the European Working Time Directive [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] \u0026ndash; have been tensioned to question the traditional quality, quantity, and need for training in surgical education. From this perspective, there has been much discussion about the issues that justify the creation and implementation of structured surgical training programs in undergraduate curricula [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhen considering the characteristics of the current world of work, ethical issues, and bioethics, training institutions must invest in well-qualified human resources, based on teaching and learning methods and resources that are compatible with the health needs of the population. Among ethically accepted teaching and learning methods is clinical simulation [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMost simulation-based initiatives achieve a reasonable improvement in learner skills and confidence. In surgical education, simulation-based learning is an important step towards training a safer and more efficient generation of surgeons [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Optimizing these efforts can be accelerated by developing simulators for basic surgical training at the undergraduate level [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Current evidence shows that incorporating the use of animal tissue or other simulation methods into undergraduate educational programs can be a catalyst for advancing surgical education [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Simulators, regardless of whether they use animal tissue (\u003cem\u003ewet lab\u003c/em\u003e), non-animal devices (\u003cem\u003edry lab\u003c/em\u003e), or even corpses, allow for different levels of fidelity that can be adjusted to the expectations of surgical teaching. Lower-fidelity, low-cost modules would be aimed at basic surgical training, while higher-fidelity, high-cost modules can be reserved for teaching more advanced students [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. When simulators are associated with surgical environment contexts and issues involving decision-making, they can significantly improve the quality of care provided [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMany skills and competencies can be developed in surgery in the context of undergraduate medical education. However, in various realities, especially in the Latin American context, these possibilities are limited by issues that involve investments in teacher training, the acquisition of simulators of different technological levels, and the acquisition and/or development of instruments and other technologies. These limitations can contribute to widening inequalities in health training and the tendency to use traditional teaching and learning methods [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAmong the various skills required by a surgeon and general practitioners in general, given their frequency in practice and clinical relevance to the patient's prognosis, is thoracentesis. Thoracentesis is a procedure that aims to remove fluid or air from the pleural space, usually with a needle, for diagnosis or relief of respiratory symptoms [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThoracentesis can cause several complications, which emphasizes the importance of training in a simulated environment. The main complications of thoracentesis include pneumothorax, hemothorax due to injury to intercostal vessels, re-expansion edema, pain at the puncture site, empyema, soft tissue infection, and accidental puncture of abdominal viscera such as the liver and spleen. Pneumothorax is the most common complication, occurring in up to 20% of cases, related to medical inexperience, large-gauge needles, excessive extraction of pleural fluid, multiple punctures, chronic obstructive pulmonary disease, repeated thoracenteses, and pleural loculations. Despite this, thoracentesis is considered a less invasive procedure and is the method of choice for obtaining pleural fluid samples, to improve the chance of diagnosis and minimize risks [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eClinical simulation can be a viable and reliable strategy for learners to achieve competencies and skills in the subject. In a simulated clinical environment, curricula with simulated thoracentesis practice increased residents' skills, appreciation of training, evaluation, and feedback [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. At its most relevant degree of impact on practice [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], evidence shows that prior thoracentesis training of residents improves patient care outcomes [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Therefore, recognizing the benefits of clinical simulation for teaching this technique justifies its inclusion in curricula and simulation programs.\u003c/p\u003e \u003cp\u003eStudies available in the literature have already presented simulator and simulation models for teaching and training the thoracentesis technique, mainly focusing on newly qualified doctors [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. However, developing and sharing different educational technologies contributes to their widespread dissemination and reproducibility in different teaching and learning contexts.\u003c/p\u003e \u003cp\u003eIn this context, this study aimed to build and validate a low-cost simulator and a clinical simulation scenario for teaching the thoracentesis surgical technique to undergraduate medical students.\u003c/p\u003e"},{"header":"Material and Methods","content":"\u003cp\u003eThis is a methodological study carried out at a public university in the interior of the state of S\u0026atilde;o Paulo, Brazil. Methodological research involves three processes, namely technology development, production, and construction Polit and Beck (2011) [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The methodological steps of this study are presented in three stages, namely:\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStage 1 - Development and construction of a low-cost simulator\u003c/h2\u003e \u003cp\u003eTo develop and build the low-cost simulator, the research team asked the following question: What attributes are needed to build a low-cost simulator for teaching the thoracentesis surgical technique?\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eRealism: the simulator should provide an experience that can reproduce thoracentesis and pleural drainage procedures as realistically as possible, taking into account the correct techniques for carrying them out, as well as tactile and visual sensory experiences.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eReproducibility: the simulator should allow for multiple uses and easy replacement of disposable parts once it has reached its useful life.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eLow cost: the simulator should have lower production and maintenance costs than those quoted for prefabricated simulators available for the same purpose.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eAfter defining the attributes, a search was made for materials in the local trade (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) and a prototype drawing of the simulator's structure was made (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. \u003cb\u003eResearched material resources that were justified according to the established criteria, Bauru, 2023.\u003c/b\u003e\u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. \u003cb\u003eSchematic model of the simulator, Bauru, 2023.\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eStage 2 - Building the clinical simulation scenario.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eTo build the clinical simulation scenario, we used the criteria of Fabri et al (2017) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], which consider the following structuring elements: the student's prior knowledge; learning objective; theoretical basis of the activity; preparation of the scenario; and evaluation.\u003c/p\u003e \u003cp\u003eInitially, intending to encourage discussion about its construction, the research team started with the following inquiry: \u0026ldquo;What information, based on the structuring elements adopted, is essential for the construction of a pleural effusion clinical simulation scenario with an indication for thoracentesis?\u0026rdquo;\u003c/p\u003e \u003cp\u003eTwo specialists in clinical simulation and two medical-surgical lecturers took part in its development. The scenario included patient care in the environment of an emergency care unit. It took into account the cognitive, affective, and psychomotor domains [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] and was based on evidence [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStage 3 - Clinical simulation scenario validation processes\u003c/h2\u003e \u003cdiv id=\"Sec5\" class=\"Section3\"\u003e \u003ch2\u003eFace and content validation\u003c/h2\u003e \u003cp\u003eThe criteria proposed by Fehring (1987) [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] were used to select the experts, with a minimum score of five points out of a total of 14: master's degree (4 points), master's dissertation in the area of interest of the study (1 point), doctoral thesis in the area of interest of the study (2 points), clinical practice with one year or more of experience in the subject of the study (1 point), specialization in the subject of interest of the study (2 points), publication of relevant research in the area of interest of the study (2 points) and publication of an article in the area of interest of the study in reference journals (2 points). In this study, the area of interest was clinical simulation and the topic of interest was surgical medicine. Three judges took part (100.0%) [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNext, to organize the final material, the Delphi Technique was used, which consists of a systematized method for judging information, aimed at obtaining a consensus from experts and users on a given topic, employing validations articulated in phases or cycles. The judges summarize, point out improvements, and consider the material examined in all its dimensions [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo assess the consensus between the judges, as well as the degree of agreement between them, the Content Validity Index (CVI) was used, where each item was assessed separately, followed by the instrument as a whole. To do this, two Likert scales were used with a score of one to five, where four and five corresponded to positive responses, three to neutrality, and two and one to negative responses.\u003c/p\u003e \u003cp\u003eThe instrument's index score was calculated using the Content Validity Index (CVI). A minimum value of 80% was set for both the CVI and the agreement index [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003ePilot study\u003c/h2\u003e \u003cp\u003eTo adapt the technologies built (simulator and simulated scenario), a pilot test was carried out with undergraduate medical students regularly enrolled in the 4th semester of the course. The students were invited online by a student researcher. The first ten students enrolled were included in the pilot. The pilot followed the classic cycle of simulated practice which consisted of skills training, scenario development, feedback, debriefing, and evaluation.\u003c/p\u003e \u003cp\u003eBefore the skills training and scenario development, the students took part in a dialogue lecture on the subject. They then took part in group skills training, followed by a simulated scenario, debriefing, and feedback. After the simulated practices, the students, in a meeting with the researchers, expressed their opinions on the simulator developed in this research, on the simulation scenario and suggested improvements to the practices offered. The pilot test was carried out in the skills and simulation laboratory at the researchers' institution.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eAnalysis and presentation of results\u003c/h2\u003e \u003cp\u003eThe results were presented in the form of tables, figures, and a discursive report. After the final analysis of the expert evaluations and the pilot project, the final version of the products was produced.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eEthical aspects\u003c/h2\u003e \u003cp\u003e This study was submitted to the Research Ethics Committee of the Bauru School of Dentistry and was approved under numbers 5.072.385 and 5.294.181. Acceptance to participate in the study was formalized by signing the informed consent form. As this study presents some qualitative aspects of the feedback approach, the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist was followed. [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eBuilding the low-cost simulator\u003c/h2\u003e \u003cp\u003eTo better analyze the results and have enough training material available for the students, five simulators for thoracentesis training were built identically. The estimated cost of each simulator was 18 US\u003cspan\u003e$\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eTo make the simulators easier to make and to reduce the cost of acquisition and maintenance, plastic mannequins used in the fashion retail market were used. The back of the mannequins was cut with a mini-drill saw\u0026rarr; to allow access to the inside. Next, the place where the underarm side wall would be drilled was marked to allow the ribs to be placed. The sealing gasket made from ethylene-vinyl acetate (EVA) was used as a marker at the height of the nipple line. The seal was obtained by interposing EVA and acrylic seals with 4 holes for the screws to pass through. Laser cutting was used to ensure the accuracy of the EVA and acrylic cuts. The walls of the sealing gasket and the fixing acrylic were 2 cm wide and 3 mm thick. The rectangular acrylic joint to allow the ribs to be fitted was made to measure 16.5 X 9 cm.\u003c/p\u003e \u003cp\u003eThe pork skins and ribs used were cut using the same acrylic plate as a size mould. The mannequin parts were stored in a freezer (temperature \u0026minus;\u0026thinsp;3\u003csup\u003eo\u003c/sup\u003e C) and were only assembled on the day of the skills training and development of the simulated scenario, to avoid degradation of the biological components.\u003c/p\u003e \u003cp\u003eTo faithfully mimic the sensation of puncturing the pleural space, we used pork ribs bought from a supermarket. The ribs were cut and perforated, while still frozen, to the same size as the mannequin's \"window\", respecting the same direction of inclination as the human ribs. In addition, pork skin of the same size was boiled in water at 100 degrees for 10 minutes to soften it and improve the feel of human skin. The skin was also perforated at 4 points for fixation.\u003c/p\u003e \u003cp\u003eInternally, the \"pleural space\" was constructed using a collagen deli bag, with its upper end open, making it possible to change the contents without disassembling the whole simulator each time it was used. Vacuum-sealed plastic bags with liquids inside were placed inside the bag.\u003c/p\u003e \u003cp\u003eThe assembly was fixed to the wall with two acrylic plates (inner and outer) fixed with screws and nuts with threaded knobs. The EVA sealing gasket was cut to the same shape as the window to ensure the necessary seal during punching. The pressure of the screws on the acrylic, the EVA, the collagen, the wall of the mannequin, the rib, and the skin provided the necessary seal to prevent leaks during the punctures.\u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. \u003cb\u003eAssembly of the simulator, Bauru, 2023.\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe simulators developed were placed on a surgical table with the fields and materials needed to practice the thoracentesis surgical technique. The students had the opportunity to train their skills, take part in a clinical simulation scenario, and evaluate the technologies developed.\u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. \u003cb\u003eAssembled simulators, Bauru, 2023.\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eFace and content validation by experts and the pilot study\u003c/h2\u003e \u003cp\u003eThe validation of the thoracentesis scenario and simulator was carried out with the collaboration of three judges who had the following sociodemographic characteristics: specialization in general surgery (66.6%) and thoracic surgery (66.6%), with an average time working in the area of 17.6 years (minimum of 10 years and maximum of 30 years), with a doctorate (66.6%), experience in clinical simulation (100.0%) and scientific production in the area of surgery and simulation (100.0%).\u003c/p\u003e \u003cp\u003eRegarding the simulator, there was 100% agreement between the experts in the first evaluation process. Concerning the proposed scenario, adjustments were made and, after the second round of evaluation, there was 100% agreement on all the items in the scenario. Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the items modified in the scenario.\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\u003eItems assessed and suitable for the proposed simulated clinical scenario, Bauru, 2023.\u003c/p\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=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" 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\u003eItems assessed\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRound 1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRound 2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eModified items\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCVI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCVI\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary objective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary objectives\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e80.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAdjusting verbs, withdrawal of inspection, palpation and percussion.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTarget audience\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheoretical foundation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaterial resources\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eActor and simulator characterization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical case\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e60.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTaken from the physical examination inspection, palpation and percussion\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplementary tests\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e70.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrinted complementary tests introduced (X-ray and full blood count), given to the student when requested. Leukocytosis, replaced by leukocytosis with left shift.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudent case description\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEvaluation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e90.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eObjective Structured Assessment of Technical Skill\u003c/em\u003e (OSAT) included\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\u003eThe pilot study consisted of skills training and scenario development. It took place in the clinical simulation laboratory and was complemented by debriefing, feedback, and student evaluation. Ten 4th year undergraduate medical students took part in this stage of the pilot study. Among the students, five (50.0%) were female, and five (50.0%) were male; six (60.0%) reported that they carried out training in the skills and simulation laboratory voluntarily and as a complement to their undergraduate activities.\u003c/p\u003e \u003cp\u003eThe students considered the clinical case to be well formulated. However, they pointed out that there was too much information, indicating that this could jeopardize the execution of the tasks set out in the scenario. They therefore suggested improvements in clarifying the clinical case, the inclusion of printed exams, and greater objectivity in the information and instructions on the tasks to be carried out. Table\u0026nbsp;3 shows the clinical simulation scenario in its final version, after the inclusions and exclusions suggested by the judges and students.\u003c/p\u003e \u003cp\u003e \u003cb\u003eTable\u0026nbsp;3. Scenario of patients with pleural effusion, according to the criteria proposed by Fabri et al (2019).\u003c/b\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe teaching of medical skills, especially surgical procedures such as chest drainage, faces significant challenges in a context where the need to balance practical training with patient and health professional safety is a pressing issue. To this purpose, the adoption of teaching methods that promote technical competence without exposing patients to unnecessary risks becomes crucial [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eClinical simulation is a teaching method that takes patient safety into account [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Well-structured simulated practice activities have an impact on student motivation [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e] and enable not only the acquisition of diagnostic and therapeutic skills but also the development of competencies such as decision-making, teamwork, and effective communication [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The resources for clinical simulation sessions include simulators.\u003c/p\u003e \u003cp\u003eSimulators are technologies designed to reproduce and/or represent a device, body part, or service [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Simulators and simulated patients contribute to the emotional preparation of students, as they allow them to practice their skills in planned activities, allowing feelings such as anxiety and stress to be worked through, as well as enabling better learning to be achieved [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn general, low-cost simulators are usually developed using alternative materials that are easy to acquire and cost less than the reference models available on the market [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe literature does not determine that more realistic simulators contribute more to learning than a low-fidelity simulator [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e] what determines the resource to be used is always the learning objective of the activity [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. Therefore, depending on the learning objectives set, the use of low-cost simulators can guarantee the effectiveness of simulation in the context of the teaching and learning process [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eLow-cost simulators, although less sophisticated in terms of technology when compared to robotic simulators, are capable of providing significant learning experiences when incorporated into simulated scenario contexts, allowing procedures to be repeated and errors to be corrected in a controlled environment and without risk to real patients, at a low cost to educational institutions [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFrom a conceptual point of view, low-cost simulators have essential attributes, namely: cost, accessibility, technologies, manufacture and reproducibility, realism, versatility, and usability. In this study, the simulator was built based on three of these: realism, reproducibility, and cost.\u003c/p\u003e \u003cp\u003eAs such, the simulator built has three fundamental characteristics: low-tech, handmade, and low-cost. It is classified as low-tech because it does not have technological resources such as electrical and electronic devices, software, or advanced technology. It can also be assembled intuitively. It was produced by hand, i.e. in a non-industrial environment, with hand tools and accessible materials, and in low demand. Finally, the low cost, given that industrial simulators for the same purpose cost much more than the one produced by the research team.\u003c/p\u003e \u003cp\u003eThe simulator that has been built enables training in thoracentesis surgical skills. It was well evaluated by experts and students in the pilot project. It can also be reproduced for use in other procedures such as cystostomy, paracentesis, and jugular puncture, among many others, and can also be used for training and assessing professionals.\u003c/p\u003e \u003cp\u003eIn addition to the industrial materials used to build the simulator in the report, the authors chose to include animal tissue (pig skin and ribs). However, these materials can be replaced with synthetic skin, easily made from silicone rubber.\u003c/p\u003e \u003cp\u003eOther studies have also reported on the use of fruit, meat, and animal tissue as an alternative to increasing the realism of simulated training [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. A study carried out in 2019 in Brazil presented the construction of two simulators: one for venous access and one for renal biopsy. The simulators were built with chicken breast, Penrose drain, plastic straw, and pig kidney. The authors report that the simulators allowed immediate identification of anatomical structures of interest and enabled the development of skills needed to perform invasive procedures [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAnother Brazilian study developed a training model using tomatoes to acquire ophthalmological microsurgical skills. The models developed proved to be viable for training microsurgical dissection [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA study, also carried out in Brazil, developed a low-cost simulator for teaching the repair of obstetric anal sphincter injuries. In addition to other materials, beef was used. The simulator allowed participants to improve their knowledge of anatomy and physiology, and to develop surgical competencies and skills [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIt's important to note that the literature points to a tendency to classify simulators that use biological materials as handmade simulators. However, the authors of this article believe that \"handmade\" refers to the production method. In this way, low-cost simulators can be produced in an artisanal, industrial, or mixed way.\u003c/p\u003e \u003cp\u003eArtisanal simulators are developed and produced in a non-industrial environment, using manual and/or mechanical equipment and tools, with alternative and accessible materials, produced to specific demands, on a low scale, or an experimental basis.\u003c/p\u003e \u003cp\u003eIt's also worth pointing out that, in terms of cost, considering the characteristics of perishable foods and the need for continuous replacement, simulators that use prime meats can have a high cost. Furthermore, low or high cost can have different connotations. A \"low cost\" in developed countries can be considered a \"high cost\" in developing or underdeveloped countries [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn this study, the simulator had a final cost of 18 US dollars, characterizing it as low-cost, given that similar models available in the simulator industry cost between 1,600 and 3,000 dollars.\u003c/p\u003e \u003cp\u003eA similar simulator, developed in the city of Fortaleza, Brazil, cost US\u003cspan\u003e$\u003c/span\u003e21.00. In addition, the results point to its easy reproducibility and usefulness for teaching chest drainage [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA study carried out in southern Brazil with 49 medical students compared student safety in the closed chest drainage procedure in a low-cost model (synthetic, 3D printed) with an animal model (pork ribs). Although a higher score was observed in the synthetic model group for learning the chest drainage technique when compared to the animal model group, there was no statistical significance between the groups. There was a preference for the 3D model. The cost of the simulator developed was also lower than those available on the market [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eJudges with expertise in surgery validated the clinical simulation scenario. In the first round of evaluation, only four criteria did not obtain a CVI of 100.0%. Therefore, the researchers decided to make the adjustments shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and send the scenario for another round of evaluation. After two rounds of evaluation, all the items reached 100.0% agreement. In addition, the scenario was also evaluated by students in a pilot study, adding clarification and complementary resources.\u003c/p\u003e \u003cp\u003eA clinical simulation scenario is an extremely important tool for planning, conducting, and evaluating simulated clinical experiences. A well-structured scenario with clear learning objectives can result in meaningful experience and learning [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e]. To this end, as presented in the results found and suggested by the experts, they should be constructed with clear language and incorporate significant data into their execution.\u003c/p\u003e \u003cp\u003eThe use of technologies such as the low-cost simulator and the scenario validated in this study can be considered a relevant cost-effective strategy for training healthcare professionals and, as highlighted in this research, future doctors.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eA low-tech, handmade, low-cost simulator was built and validated for training in the surgical technique of thoracentesis and a clinical simulation scenario for managing patients with pleural effusion.\u003c/p\u003e \u003cp\u003eAlthough this study has some limitations, such as the small number of judges and the lack of evaluation of the simulator's usability, which will be carried out in a later study, it was noted that the simulator had a much lower final cost than other models available in the industry. The desired realism was achieved in that it allowed thoracentesis and pleural drainage techniques to be carried out with sensory and visual characteristics that were very close to reality. Furthermore, the simulator parts can be built and replaced after multiple uses. Therefore, it can be reproduced easily with few resources.\u003c/p\u003e \u003cp\u003eIn this study, the simulator built and the scenario presented were validated and considered suitable by experts in the field. They were also considered suitable by users (students). We therefore encourage the incorporation of these teaching resources, as well as future studies that can further expand the understanding of the impacts of their use and the learning of clinical skills.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEVA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEthylene-vinyl acetate\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCVI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eContent Validity Index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRAM thanks to Gabriel Ara\u0026uacute;jo Medeiros and Jan Beatriz Felinto de Santana for providing writing and image editing services, and to the University of S\u0026atilde;o Paulo for providing their locations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. The authors alone are responsible for the content and writing of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; information\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRoberson Antequera Moron https://orcid.org/0000-0003-1115-7276\u003c/p\u003e\n\u003cp\u003eVictor Cardozo https://orcid.org/0009-0008-7301-7934\u003c/p\u003e\n\u003cp\u003eMarcos Antonio Marton Filho https://orcid.org/0000-0003-0234-1258\u003c/p\u003e\n\u003cp\u003eAlessandra Mazzo https://orcid.org/0000-0001-5074-8939\u003c/p\u003e\n\u003cp\u003eRaphael Ranieri de Oliveira Costa https://orcid.org/0000-0002-2550-4155\u003c/p\u003e\n\u003cp\u003eCarlos Ferreira dos Santos https://orcid.org/0000-0002-0405-3500\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors and Affiliations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBauru School of Dentistry (FOB) and Craniofacial Anomalies Rehabilitation Hospital (HRAC), University of S\u0026atilde;o Paulo, S\u0026atilde;o Paulo, Brazil.\u003c/p\u003e\n\u003cp\u003eRoberson Antequera Moron\u003c/p\u003e\n\u003cp\u003eBauru Medical School, Department of Pediatric Dentistry, Orthodontics, and Public Health, Bauru School of Dentistry, University of S\u0026atilde;o Paulo, Bauru, Sao Paulo, Brazil.\u003c/p\u003e\n\u003cp\u003eVictor Cardozo, Marcos Antonio Marton Filho, Alessandra Mazzo\u003c/p\u003e\n\u003cp\u003eMedicine Course, Federal University of Rio Grande do Norte (UFRN), Caic\u0026oacute;, Rio Grande do Norte, Brazil.\u003c/p\u003e\n\u003cp\u003eRaphael Ranieri de Oliveira Costa\u003c/p\u003e\n\u003cp\u003eBauru School of Dentistry (FOB) and Craniofacial Anomalies Rehabilitation Hospital (HRAC), University of S\u0026atilde;o Paulo, S\u0026atilde;o Paulo, Brazil.\u003c/p\u003e\n\u003cp\u003eCarlos Ferreira dos Santos\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRAM made the idealization and conducted all the stages of the study. VC and MAMF participated in stages 2 and 3, RAM elaborated the clinical case, CFS and AM were supervisioners during all the study. RAM wrote the main manuscript. RAM, RROC and AM made the final revision and writing corrections to the paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was performed in accordance with the declarations of Helsinki, under approval of the Research Ethics Committee of the Bauru Dental School of the University of Sao Paulo (CAAE 5.072.385 and 5.294.181). Acceptance to participate in the study was formalized by signing the informed consent form. Supporting documents are held by the researchers and are available to editors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData is available upon request from the first author.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKneebone R, Aggarwal R. Surgical training using simulation. 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Med (Ribeir\u0026atilde;o Preto) [Internet]. 2022;55(3):e\u0026ndash;192299. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.11606/issn.2176-7262.rmrp.2022.192299\u003c/span\u003e\u003cspan address=\"10.11606/issn.2176-7262.rmrp.2022.192299\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Constru\u0026ccedil;\u0026atilde;o e valida\u0026ccedil;\u0026atilde;o de cen\u0026aacute;rio de simula\u0026ccedil;\u0026atilde;o m\u0026eacute;dica no ensino de imuniza\u0026ccedil;\u0026atilde;o.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 and 3 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Simulation Training, Validation Study, Low-Cost Technology, Thoracic Surgical Procedures, Cost, Undergraduate","lastPublishedDoi":"10.21203/rs.3.rs-3796982/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3796982/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThoracentesis yields valuable insights in pleural effusion diagnosis by accurately interpreting pleural fluid analysis results and can cause several complications, which emphasizes the importance of training in a simulated environment. There are many expensive simulators related to this procedure and few validated scenarios. This study aimed to build and validate a low-cost simulator and a clinical simulation scenario for teaching the thoracentesis surgical technique to undergraduate medical students.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis is a methodological study carried out at a public university in the interior of the state of S\u0026atilde;o Paulo, Brazil. It was carried out in three methodological stages, namely: 1) Construction of the simulator, which involved planning, surveying, pricing, and use of material resources 2) Construction of a simulated thoracentesis scenario, based on literature and a simulation script and 3) Validation by experts and pilot study of the simulator and scenario. Experts were selected according to Fehring criteria.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe simulator proved to be suitable and low-cost (US \u003cspan\u003e$\u003c/span\u003e18). Modifications to the scenario were suggested by the experts and students in the pilot study, with 100.0% agreement.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eIn conclusion, a low-tech, handmade, and low-cost simulator was built and validated for training in the thoracentesis surgical technique, as well as a clinical simulation scenario for the management of patients with pleural effusion, which can be included in various medical teaching contexts.\u003c/p\u003e","manuscriptTitle":"Construction of a Simulation Scenario and a Low-Cost Simulator for Teaching Thoracentesis Surgical Technique: A Validation Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-12-29 14:11:34","doi":"10.21203/rs.3.rs-3796982/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-06-04T15:26:05+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-06-04T11:42:07+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2023-12-23T19:42:31+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2023-12-23T15:22:07+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0731f9b0-f29f-4d04-9e75-8c7c0caee1ef","owner":[],"postedDate":"December 29th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-07-07T16:06:12+00:00","versionOfRecord":{"articleIdentity":"rs-3796982","link":"https://doi.org/10.1186/s12909-025-07381-7","journal":{"identity":"bmc-medical-education","isVorOnly":false,"title":"BMC Medical Education"},"publishedOn":"2025-07-01 15:58:10","publishedOnDateReadable":"July 1st, 2025"},"versionCreatedAt":"2023-12-29 14:11:34","video":"","vorDoi":"10.1186/s12909-025-07381-7","vorDoiUrl":"https://doi.org/10.1186/s12909-025-07381-7","workflowStages":[]},"version":"v1","identity":"rs-3796982","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3796982","identity":"rs-3796982","version":["v1"]},"buildId":"_2-kVJe1T_tPrBINL-cwx","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}