Impact of simulator-based chest tube insertion training on surgical residents’ confidence and technical proficiency

Impact of simulator-based chest tube insertion training on surgical residents’ confidence and technical proficiency | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Impact of simulator-based chest tube insertion training on surgical residents’ confidence and technical proficiency Maher Abdessater, Ramy Touma Sawaya, Pascal Roquet, Raghid El Khoury This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7171613/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective : This study aims to assess the efficiency of impact simulation models on surgical resident’s skill and confidence to perform chest tube insertion Design : This study deployed both questionnaires to assess textbook and medical knowledge relating to chest tube insertions, and simulation models to assess technical skills required for adequate insertion. Both parts of the study were done before and after a lecture-based debriefing session was done to evaluate the improvement of the participants with both traditional lecture-based and simulation learning. Setting : This study was done at the simulation center in the University of Kaslik, Lebanon Participants : 74 surgical residents from postgraduate years 1 and 2 were recruited into the study, and were randomly assigned into one of six groups to undergo a simulation session divided into six stages Results : Prior to the debriefing session, the reported confidence level was 2.25±1.25, the technical skills score was 3.5±2.9 out of 16 and the nontechnical skills score was 6.5±2.5 out of 16. After a debriefing session, the reported confidence level increased to 5.24±2.21, the technical skills score increased to 7.8±1.3 and the nontechnical skills score increased to 9.7±1.1. Older postgraduate year, and higher initial confidence were found to significantly improve technical and nontechnical skills scores (OR = 0.91; 95% CI: 0.81–0.99; p = 0.04 and OR = 0.93; 95% CI: 0.79–0.97; p = 0.01, respectively) Conclusions : Exposure to invasive procedures such as chest tube insertions can be given efficiently when incorporating traditional lecture-based learning with simulation models for hands-on experience, especially in the scarcity of patients requiring such a procedure. Furthermore, the importance of building confidence in medical students and residents must be studied further to improve medical education and patient care. Simulation Confidence Chest tube insertion invasive procedure technical skills Figures Figure 1 Introduction Chest tube insertion (CTI) is a crucial procedural skill that physicians must perform competently and quickly, as it can be lifesaving. This procedure is applicable for treating various medical conditions, such as pneumothorax, hemothorax, chylothorax, empyema, and esophageal rupture into the pleural space 1 . On the other hand, it can lead to significant adverse outcomes, including iatrogenic pneumothorax or hemothorax, infection, organ puncture, and, in rare cases, death 2 . As CTI becomes an increasingly rare procedure, it is often challenging for surgical interns to complete a sufficient number of procedures solely on clinical experience 3 . This difficulty presents challenges in ensuring adequate training for all learners, and underlines the need for improved training techniques in performance of this procedure 4 – 6 . In addition, given the significant risk of complications associated with CTI, it is crucial for medical educators to understand the best methods of improving competency and confidence in performing this technique. Medical simulation is an effective teaching method that enhances patient safety and care. It allows trainees to experience scenarios that closely mimic real-life situations, supporting daily medical decision-making and technical skills. Additionally, simulation in the medical field helps identify limitations and technical failures in procedures performed by medical students, interns and residents 7 . Moreover, simulation sessions have been shown to improve competence, confidence, and reduce CTI complication rates 8 , 9 . Understanding the reciprocal relationship between self-confidence and efficacy is essential for educators, trainers, and individuals themselves. By intentionally fostering self-confidence and efficacy through skill-building activities such as medical simulation, individuals can create a self-reinforcing cycle that strengthens both concepts and maximizes their potential for success in various medical field trainings, including CTI. This article aims to explore the relationship between simulation-based training, self-confidence, and efficacy of surgical interns in CTI learning, as well as its predicting factors. Material and methods This study is based on a "pretest-posttest" design model. Surgical residents of post-graduate year (PGY) 1 and 2 participated in the study. In total, seventy-four participants were included. Six simulation sessions were done. To clearly outline the steps of the evaluation methodology for simulation exercise, every session was divided into six main stages, based on the basic principles of medical simulation. These stages are simplified in figure 1. Time T0 (Participant allocation and introduction): First, the research team explained the study’s goals and aims, disclosed the minimal risks of injury due to handling sharp medical equipment, and confirmed full anonymity and participant rights to each resident. Interested residents then signed of the written informed consent to verify their full understanding and willingness to participate. Participants were randomly divided into three groups, ranging from 10 to 12 medical residents per group, and were invited to simulation sessions over several days at the simulation center of the university hospital. Before the session, a brief introduction explained the progression of the different planned stages. Participants were then invited to draw a number that would serve as their identifier throughout the session, ensuring their anonymity. Time T1 (pre-procedural self-assessment): An initial self-assessment questionnaire using the “Google Forms” platform was distributed via a QR code. The first section of the form explained the study’s aims and process in detail and included 1 question to obtain the participant’s consent to participate in the simulation session and study. It was followed by a section tackling several socio-demographic questions, including gender, year of training, the number of attempts of the procedure, and their confidence level in performing this procedure. The final section included six additional questions, participants were also asked about their basic knowledge of the procedure, specifically indications, contraindications, key elements such as anatomical landmarks, size of the tube, and depth of insertion. Time T2 (initial scenario execution): Participants were then invited to practice the simulated procedure on TruMan Trauma System which is an anatomically correct, simulated human torso with an AirSim head and replaceable tissues. Meanwhile, senior thoracic surgery residents observed and evaluated the intern's performance using a structured and objective assessment grid of technical skills, based on the modified and adapted American model “Objective Structured Assessment of Technical Skill (OSATS)” for each exercise 10 . Each participant was assessed for their technical skills (TS) and non-technical skills (NTS). These skills are further detailed in the appendix. A final "pass or fail" question was added at the end of the evaluation form. Time T3 (debriefing): After being evaluated, participants attended a fifteen-minute slideshow presentation where the indications, contraindications, procedure steps, and methods for reporting results were thoroughly reviewed step by step. The presentation was based on scientific references related to each exercise. It was followed by a video demonstrating the steps of the procedure to be simulated, using the same references. Time T4 (post-debriefing scenario execution): All participants were invited to repeat the simulation exercise under the same conditions as in T2. They were re-evaluated by the same examiners using the same evaluation tool for their TS and NTS. Time T5 (post-procedural self-assessment): A second QR code was provided, redirecting participants to a post-procedural self-assessment questionnaire which again targeted their medical, anatomical, and technical knowledge of the procedure. During this final stage, they completed the questionnaire regarding their level of satisfaction with the simulation session. Data Analysis: The collected data were compiled, coded, and analyzed using SPSS v.26 software (IBM SPSS Inc., Chicago, IL, USA). There was no missing data as all forms were completed exclusively online, and answering all questions was a mandatory step before online submission to start the session. Continuous variables were reported as means and standard deviations (SD), while categorical variables were represented as frequencies and percentages. Four scores were calculated: the first and third were pre- and post-intervention TS scores, which were the sum of the points in the TS assessment. The second and fourth were pre- and post-intervention NTS scores, calculated by summing up the points related to NTS. Normality was tested by visual inspection using a histogram and normality curve. For bivariate analysis, the t-test was used to compare means of continuous variables before and after the intervention, while the McNemar test was used to compare proportions. Finally, the Student’s T-test was used to compare means of non-repeated measures. A p-value of less than 0.05 was considered significant. RESULTS This study recruited 74 participants in total. There were 35 (47.3%) males and 37 (50%) females, with 2 (2.7%) participants not specifying their sex. 42 (56.8%) participants were in the PGY1 year, while 32 (43.2%) were in the PGY2 year. Grade scores during their internship years were tabulated and divided, finding that 19 (25.7%) had final year average scores below 70%, while 55 (74.3%) had scores above 70%. These demographic factors are included in Table 3 . At T1, the confidence level for the procedure had a mean of 2.25 ± 1.25 SD, indicating a low level of confidence. The confidence level increased 5.24 ± 2.21 at T5. However, this difference was not statistically significant (p = 0.3). During T2, the assessment of their CTI according to the OSATS score revealed a TS average of 3.5 ± 2.9 SD (For a maximum score of 16). As for non-technical skills, the average score was 6.5 ± 2.5 SD (For a maximum score of 16). Even though after exercise both scores were found to be higher as TS score was 7.8 ± 1.3 SD and 9.7 ± 1.1 SD for CNT), this increase remained statistically insignificant with a p-value of 0.2 and 0.5, respectively. The results of OSATS score variation and confidence level between T2 and T4 are displayed in Table 1 . Table 1 Variation of confidence level between T1 and T5, and OSATS score between T2 and T4 Variable Stage Mean ± SD p-value Confidence scale (out of 10) T1 2.25 ± 1.25 0.3 T5 5.24 ± 2.21 OSATS TS (out of 16) T2 3.5 ± 2.9 0.2 T4 7.8 ± 1.3 OSATS NTS (out of 16) T2 6.5 ± 2.5 0.5 T4 9.7 ± 1.1 At the end of T4, the average rating given to the simulation training by the interns was 3.8/5. The majority (98.6%) recommend the training to other interns. The results of the final questionnaire are summarized in Table 2 . Table 2 Summary of the participants' final assessment of the CTI exercise Domain Response N % Satisfaction Very good 70 94.50% Good 4 5.50% Quality of training Very good 67 90.50% Good 7 9.50% Response to the participants' needs Very good 65 87.80% Good 9 12.20% Usefulness of skills acquired in daily practice Yes 71 96% Non 3 4% Recommendation of the exercise to other trainees Yes 73 98.60% No 1 1,4% Mean ± SD Min Max Overall rating for this training (from 1 to 5): 3,8 (0,5) 3 5 How satisfied are you? (from 1 to 5): 3,7 (0,4) 3 5 How well did the presenter explain the objectives? (1 to 5): 4,2 (0,5) 4 5 How do you rate the duration of the training? (from 1 to 5): 3,2 (1,1) 1 5 Univariate and multivariate statistical analysis was then conducted to find a correlation between confidence levels and OSATS scores at the end of the simulation, in relation to certain independent variables. It was found that women had higher confidence levels than men but without impact on OSATS scores. Also, students with higher grade averages in the internship exams had higher confidence levels and technical skills identical to students with lower averages. Finally, the internship year has no impact on confidence levels or OSATS scores. The results are detailed in Table 3 . Table 3 Correlation between demographic factors and the confidence level, OSATS-TS, and OSATS-NTS at the end of training Variable Population N (%) Confidence level (out of 10) ± SD p-value OSATS-TS (out of 16) ± SD p-value OSATS-NTS (out of 16) ± SD p-value Sex Male 35 (47.3%) 7.26 ± 1.8 0.6 11.6 ± 2.1 0.5 11.5 ± 3.1 0.6 Female 37 (50%) 8.26 ± 2.2 0.01 11.8 ± 1.9 0.6 11.06 ± 2.2 0.8 PGY 1 42 (56.8%) 7.6 ± 0.8 0.8 11.0 ± 0.8 0.4 12.56 ± 2.5 0.7 2 32 (43.2%) 7.98 ± 1.1 0.5 12.4 ± 1.6 0.8 10 ± 3.3 0.5 Grades during internship exams 70/100 55 (74.3%) 7.42 ± 0.9 0.6 11.6 ± 0.5 0.7 12.8 ± 1.2 0.2 In multivariate analysis, PGY1s were more likely associated with reduced improvement in OSATS scores between T2 and T4 than PGY2s (OR = 0.91; 95% CI: 0.81–0.99; p = 0.04). Similarly, lower levels of confidence reported at T1 were independently associated with reduced improvement of OSATS scores between T2 and T4 (OR = 0.93; 95% CI: 0.79–0.97; p = 0.01). However, grade averages during internship year (OR = 1.30; 95% CI: 0.98–2.46; p = 0.60) and female sex were not significantly associated with changes in OSATS scores between T2 and T4. These results are shown in Table 4 . Table 4 Predictive factors for OSATS score increase between the first and second simulation Univariate analysis Multivariate analysis Variable Odds Ratio 95%- confidence interval p Odds Ratio 95%- confidence interval p First year of internship 0.95 0.86–1.10 0.03 0.91 0.81–0.99 0.04 Grade averages during internship exams 1.41 0.79–3.01 0.12 1.3 0.98–2.46 0.6 Female sex 0.95 0.89–1.30 0.11 1.1 0.93–1.41 0.97 reduced initial level of confidence 0.92 0.89–1.10 0.03 0.93 0.79–0.97 0.01 Discussion This study examines intern capabilities during their first residency years when encountering a new invasive technique, identifying factors that can predict their improvement, exploring methods to enhance practical, hands-on medical education, and emphasizing the value of simulation sessions before performing invasive procedures on patients. The increase in confidence levels, and improvement of OSATS scores after a detailed procedural debriefing can indicate that interns may improve their skills with adequate practice, even if on a simulator model rather than a real patient, similar to a 2016 study by Léger et al. which showed that simulation-based training models with didactic lectures improved the success rate of chest tube insertions when compared to lecture based learning methods alone 11 . However, the statistical insignificance, with a p-value of 0.3 for confidence levels, 0.2 for TS and 0.5 for NTS may indicate the need for reassessment with a larger population size that includes a diverse array of residents from various medical and surgical specialties, as done in a 2020 study by Bevilacqua et al. which showed that introducing simulation sessions for incoming surgical residents of various subspecialties significantly improved confidence and self-efficacy during invasive procedures 12 . A 2020 study by Tawfik et al. looked into the efficiency of simulation sessions, as opposed to traditional didactic learning, in medical students while considering their interest and attentiveness, concluding that while the efficacy of simulations is very similar to those of lecture based learning, students had more positive opinions towards simulations regarding their motivation to learn, ability to practice, and overall satisfaction 13 . Similarly, when looking into participant satisfaction with the use of debriefing and simulation sessions for procedure and technical education, a score of 3.8/5 indicates a high level of satisfaction. This may be an indication that live-teaching and hands-on learning, even on simulated models, increases student attention, promotes participation and improvement of technique, and advances technical skills that are essential and lifesaving during patient interactions. However, many factors can come into play when assessing satisfaction. The presence of the educator, while participants fill the survey may push towards more positive responses as a show of respect towards the educator. The proximity of the feedback directly after completion of the simulation session may cause emotional liability and limit the time to fully consider each response. While these factors are theoretical and may be unavoidable, it is important to identify such confounding variables when analyzing the study’s impact. When performing the univariate and multivariate analysis, the identification of postgraduate year and initial confidence level were the only predictive variables to significantly affect OSATS scores, with interns at the PGY1 level or those with lower initial confidence levels having reduced OSATS score variations and thus reduced levels of improvement with simulation and debriefing sessions, similar to a 2019 study by Liepert et al. which showed that younger interns were more likely to have reduced variations in improvement as compared to their older counterparts, who were more likely to master the technique and report reduced anxiety and increased confidence by PGY2 14 . While the increased experience of a PGY2 over a PGY1 intern is an undeniable variable in evaluating score improvement, the variable of confidence levels affecting the variations in OSATS scores may identify the importance of confidence when performing medical procedures, and that lower levels of confidence, even with increased practice or advanced knowledge, may significantly hinder optimal medical care, especially during invasive procedures such as CTI. While this study shows the significance of confidence in performing invasive procedures, this idea must be reassessed with larger populations, possibly with stratifying based on level of PGY, to properly identify the roots of lower confidence levels, reducing possible confounding variables, and how the medical education systems worldwide can boost self-confidence and practical skills from earlier in the medical education programs. Conclusion The use of simulations and models has been proven to be efficient and essential tools for improving technical skills relating to CTIs. This study also identifies confidence as a significant variable towards improving hands-on skills relating to CTIs, opening future possibilities of research into the effects of confidence on other invasive procedures. Medical schools and residency programs can find ways to improve confidence levels earlier during the medical education pathway, while maintaining high standards of education in medical knowledge and patient contact, to ensure advancements in the medical fields and promote higher standards of care. Abbreviations OR: Odds Ratio; CTI: Chest Tube Insertion; PGY: Post Graduate Year; T: Time; OSATS: Objective Structured Assessment of Technical Skill; TS: Technical Skills; NTS: Non-technical Skills; SD: Standard Deviation. Declarations Human Ethics and Consent to Participate: This study was initially approved by the IRB team in the university of USEK. The study was supervised thoroughly in order to adhere to the Helsinki Declaration. Informed consent was gained from each participant during study explanation and prior to starting. Consent to Publish : gained from each participant during study explanation and prior to starting. Availability of data and materials: Data is available upon request from the corresponding author. Competing Interests: None Funding : This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Authors' contributions : M.A. initiated the study and supervised all aspects of data collection. He is the primary author. R.T.S. wrote the article with M.A. and analyzed the data during and after collection. P.R. and R.K. supervised and confirmed the procedures were done ethically and to standard. Both also assisted in article writing and data collection Acknowledgements: None References Ghazali D, Ilha-Schuelter P, Barbosa S, et al. Interdisciplinary teamwork for chest tube insertion and management: an integrative review. Anaesthesiol Intensive Ther . 2021;53(5):456-465. doi:10.5114/ait.2021.111349 Filosso PL, Guerrera F, Sandri A, et al. Errors and Complications in Chest Tube Placement. Thorac Surg Clin . 2017;27(1):57-67. Doi: 10.1016/j.thorsurg.2016.08.009 Review Comittee for Emergency Medicine. Emergency Medicine Defined Key Index Procedure Minimums. Published online 2017. Deilamy I, Amini M, Abbasi HR, Bolandparvaz S, Paydar S. Impact of Peer-Assisted Learning in Chest Tube Insertion Education on Surgical Residents. Bull Emerg Trauma . 2022;10(2):83-86. doi:10.30476/BEAT.2022.94348.1336 Tokuno J, Valanci-Aroesty S, Uchino H, et al. Teaching Chest Tube Insertion by Blended Learning: A Multi-Dimensional Analysis. Surg Innov . 2024;31(1):92-102. doi:10.1177/15533506231211049 Berger M, Weber L, McNamara S, Shin-Kim J, Strauss J, Pathak S. Simulation-Based Mastery Learning Course for Tube Thoracostomy. MedEdPORTAL . 2022; 18:11266. doi:10.15766/mep_2374-8265.11266 Ing L, Cheng A, Lin Y. Debriefing for Simulation-Based Medical Education: A Survey from the International Network of Simulation-Based Pediatric Innovation, Research and Education. Simul Healthc . 2022;17(1):1-6. doi:10.1097/SIH.0000000000000541 Barsuk JH, Cohen ER, Williams MV, et al. Simulation-Based Mastery Learning for Thoracentesis Skills Improves Patient Outcomes: A Randomized Trial. Acad Med . 2018;93(5):729-735. doi:10.1097/ACM.0000000000001965 Vijayakumar B, Hynes G, Kitt J, Millette S, FitzPatrick M. An effective procedure skills training programme for GIM registrars. Future Healthc J . 2021;8(1): e117-e122. doi:10.7861/fhj.2020-0090 Martin JA, Regehr G, Reznick R, et al. Objective structured assessment of technical skill (OSATS) for surgical residents. Br J Surg . 1997;84(2):273-278. doi:10.1046/j.1365-2168.1997. 02502.x Léger A, Ghazali A, Petitpas F, Guéchi Y, Boureau-Voultoury A, Oriot D. Impact of simulation-based training in surgical chest tube insertion on a model of traumatic pneumothorax. Adv Simul (Lond) . 2016 ;1:21. doi:10.1186/s41077-016-0021-2 Bevilacqua LA, Simon J, Rutigliano D, et al. Surgical boot camp for fourth-year medical students: Impact on objective skills and subjective confidence. Surgery . 2020;167(2):298-301. doi:10.1016/j.surg.2019.06.041 Tawfik MMR, Fayed AA, Dawood AF, Al Mussaed E, Ibrahim GH. Simulation-Based Learning Versus Didactic Lecture in Teaching Bronchial Asthma for Undergraduate Medical Students: a Step Toward Improvement of Clinical Competencies. Med Sci Educ . 2020;30(3):1061-1068. doi:10.1007/s40670-020-01014-y Liepert AE, Velic AJ, Rademacher B, et al. Proficiency development for graduating medical students, using skills-level–appropriate mastery learning versus traditional learning for chest tube placement: Assessing anxiety, confidence, and performance. Surgery . 2019;165(6):1075-1081. doi:10.1016/j.surg.2019.01.015 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7171613","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":512041808,"identity":"6c2990bd-c131-4008-8d15-070032e35b34","order_by":0,"name":"Maher Abdessater","email":"","orcid":"","institution":"National Conservatory of arts and crafts","correspondingAuthor":false,"prefix":"","firstName":"Maher","middleName":"","lastName":"Abdessater","suffix":""},{"id":512041809,"identity":"55eba569-f1b8-4df9-b3bf-3324e73638eb","order_by":1,"name":"Ramy Touma Sawaya","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAsklEQVRIiWNgGAWjYFAC5gMHPjAwJABZBgwMBQeI0MHGlnhwBlyLAVFaeIwP85CkxXx+W8Jhm5rDeQzszdskGAzuENYic4z5wOGcY4eLGXiOlQG1PCOsRYKNLeFwDtvhxAaJHDOglsPEaOExOGzxD6hF/g0pWhjbQLbwEK0lLeFgb196MRtPWrFFAlF+YT58+MOPb9Z5/OyHN974UEFEiMEBG4hIIEHDKBgFo2AUjAI8AAAVGjiZeRXdMwAAAABJRU5ErkJggg==","orcid":"","institution":"National Conservatory of arts and crafts","correspondingAuthor":true,"prefix":"","firstName":"Ramy","middleName":"Touma","lastName":"Sawaya","suffix":""},{"id":512041811,"identity":"362475b7-0a9d-4b66-a155-31d5f2b95118","order_by":2,"name":"Pascal Roquet","email":"","orcid":"","institution":"National Conservatory of arts and crafts","correspondingAuthor":false,"prefix":"","firstName":"Pascal","middleName":"","lastName":"Roquet","suffix":""},{"id":512041813,"identity":"9b23537f-332d-4314-b9c9-417a635f68ca","order_by":3,"name":"Raghid El Khoury","email":"","orcid":"","institution":"Doctoral College, Holy Spirit University of Kaslik (USEK)","correspondingAuthor":false,"prefix":"","firstName":"Raghid","middleName":"El","lastName":"Khoury","suffix":""}],"badges":[],"createdAt":"2025-07-20 20:08:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7171613/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7171613/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":91104079,"identity":"b989bd4d-f4b3-46c0-a4de-7a690a0cafb6","added_by":"auto","created_at":"2025-09-11 15:11:31","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":33115,"visible":true,"origin":"","legend":"\u003cp\u003eDivision of stages throughout the study.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7171613/v1/96d884e44ce51c74c8fad0da.png"},{"id":95359049,"identity":"510168b6-845d-4dca-9d2a-8140bfae83c2","added_by":"auto","created_at":"2025-11-07 07:09:06","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":856471,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7171613/v1/bf97b681-e6b0-4c28-8c52-1a29e5853db2.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Impact of simulator-based chest tube insertion training on surgical residents’ confidence and technical proficiency","fulltext":[{"header":"Introduction","content":"\u003cp\u003eChest tube insertion (CTI) is a crucial procedural skill that physicians must perform competently and quickly, as it can be lifesaving. This procedure is applicable for treating various medical conditions, such as pneumothorax, hemothorax, chylothorax, empyema, and esophageal rupture into the pleural space \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. On the other hand, it can lead to significant adverse outcomes, including iatrogenic pneumothorax or hemothorax, infection, organ puncture, and, in rare cases, death \u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eAs CTI becomes an increasingly rare procedure, it is often challenging for surgical interns to complete a sufficient number of procedures solely on clinical experience \u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. This difficulty presents challenges in ensuring adequate training for all learners, and underlines the need for improved training techniques in performance of this procedure \u003csup\u003e\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. In addition, given the significant risk of complications associated with CTI, it is crucial for medical educators to understand the best methods of improving competency and confidence in performing this technique.\u003c/p\u003e\u003cp\u003eMedical simulation is an effective teaching method that enhances patient safety and care. It allows trainees to experience scenarios that closely mimic real-life situations, supporting daily medical decision-making and technical skills. Additionally, simulation in the medical field helps identify limitations and technical failures in procedures performed by medical students, interns and residents \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. Moreover, simulation sessions have been shown to improve competence, confidence, and reduce CTI complication rates \u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eUnderstanding the reciprocal relationship between self-confidence and efficacy is essential for educators, trainers, and individuals themselves. By intentionally fostering self-confidence and efficacy through skill-building activities such as medical simulation, individuals can create a self-reinforcing cycle that strengthens both concepts and maximizes their potential for success in various medical field trainings, including CTI.\u003c/p\u003e\u003cp\u003eThis article aims to explore the relationship between simulation-based training, self-confidence, and efficacy of surgical interns in CTI learning, as well as its predicting factors.\u003c/p\u003e"},{"header":"Material and methods","content":"\u003cp\u003eThis study is based on a \u0026quot;pretest-posttest\u0026quot; design model. Surgical residents of post-graduate year (PGY) 1 and 2 participated in the study. In total, seventy-four participants were included. Six simulation sessions were done.\u003c/p\u003e\n\u003cp\u003eTo clearly outline the steps of the evaluation methodology for simulation exercise, every session was divided into six main stages, based on the basic principles of medical simulation. These stages are simplified in figure 1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTime T0 (Participant allocation and introduction):\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFirst, the research team explained the study\u0026rsquo;s goals and aims, disclosed the minimal risks of injury due to handling sharp medical equipment, and confirmed full anonymity and participant rights to each resident. Interested residents then signed of the written informed consent to verify their full understanding and willingness to participate.\u003c/p\u003e\n\u003cp\u003eParticipants were randomly divided into three groups, ranging from 10 to 12 medical residents per group, and were invited to simulation sessions over several days at the simulation center of the university hospital. Before the session, a brief introduction explained the progression of the different planned stages. Participants were then invited to draw a number that would serve as their identifier throughout the session, ensuring their anonymity.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTime T1 (pre-procedural self-assessment):\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAn initial self-assessment questionnaire using the \u0026ldquo;Google Forms\u0026rdquo; platform was distributed via a QR code. The first section of the form explained the study\u0026rsquo;s aims and process in detail and included 1 question to obtain the participant\u0026rsquo;s consent to participate in the simulation session and study. It was followed by a section tackling several socio-demographic questions, including gender, year of training, the number of attempts of the procedure, and their confidence level in performing this procedure. The final section included six additional questions, participants were also asked about their basic knowledge of the procedure, specifically indications, contraindications, key elements such as anatomical landmarks, size of the tube, and depth of insertion.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTime T2 (initial scenario execution):\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eParticipants were then invited to practice the simulated procedure on TruMan Trauma System which is an anatomically correct, simulated human torso with an AirSim head and replaceable tissues.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMeanwhile, senior thoracic surgery residents observed and evaluated the intern\u0026apos;s performance using a structured and objective assessment grid of technical skills, based on the modified and adapted American model \u0026ldquo;Objective Structured Assessment of Technical Skill (OSATS)\u0026rdquo; for each exercise \u003csup\u003e10\u003c/sup\u003e. Each participant was assessed for their technical skills (TS) and non-technical skills (NTS). These skills are further detailed in the appendix. A final \u0026quot;pass or fail\u0026quot; question was added at the end of the evaluation form.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTime T3 (debriefing):\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAfter being evaluated, participants attended a fifteen-minute slideshow presentation where the indications, contraindications, procedure steps, and methods for reporting results were thoroughly reviewed step by step. The presentation was based on scientific references related to each exercise. It was followed by a video demonstrating the steps of the procedure to be simulated, using the same references.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTime T4 (post-debriefing scenario execution):\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll participants were invited to repeat the simulation exercise under the same conditions as in T2. They were re-evaluated by the same examiners using the same evaluation tool for their TS and NTS.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTime T5 (post-procedural self-assessment):\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA second QR code was provided, redirecting participants to a post-procedural self-assessment questionnaire which again targeted their medical, anatomical, and technical knowledge of the procedure. During this final stage, they completed the questionnaire regarding their level of satisfaction with the simulation session.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Analysis:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe collected data were compiled, coded, and analyzed using SPSS v.26 software (IBM SPSS Inc., Chicago, IL, USA). There was no missing data as all forms were completed exclusively online, and answering all questions was a mandatory step before online submission to start the session. Continuous variables were reported as means and standard deviations (SD), while categorical variables were represented as frequencies and percentages. Four scores were calculated: the first and third were pre- and post-intervention TS scores, which were the sum of the points in the TS assessment. The second and fourth were pre- and post-intervention NTS scores, calculated by summing up the points related to NTS.\u003c/p\u003e\n\u003cp\u003eNormality was tested by visual inspection using a histogram and normality curve. For bivariate analysis, the t-test was used to compare means of continuous variables before and after the intervention, while the McNemar test was used to compare proportions. Finally, the Student\u0026rsquo;s T-test was used to compare means of non-repeated measures. A p-value of less than 0.05 was considered significant.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eThis study recruited 74 participants in total. There were 35 (47.3%) males and 37 (50%) females, with 2 (2.7%) participants not specifying their sex. 42 (56.8%) participants were in the PGY1 year, while 32 (43.2%) were in the PGY2 year. Grade scores during their internship years were tabulated and divided, finding that 19 (25.7%) had final year average scores below 70%, while 55 (74.3%) had scores above 70%. These demographic factors are included in Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\u003cp\u003eAt T1, the confidence level for the procedure had a mean of 2.25\u0026thinsp;\u0026plusmn;\u0026thinsp;1.25 SD, indicating a low level of confidence. The confidence level increased 5.24\u0026thinsp;\u0026plusmn;\u0026thinsp;2.21 at T5. However, this difference was not statistically significant (p\u0026thinsp;=\u0026thinsp;0.3).\u003c/p\u003e\u003cp\u003eDuring T2, the assessment of their CTI according to the OSATS score revealed a TS average of 3.5\u0026thinsp;\u0026plusmn;\u0026thinsp;2.9 SD (For a maximum score of 16). As for non-technical skills, the average score was 6.5\u0026thinsp;\u0026plusmn;\u0026thinsp;2.5 SD (For a maximum score of 16). Even though after exercise both scores were found to be higher as TS score was 7.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3 SD and 9.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1 SD for CNT), this increase remained statistically insignificant with a p-value of 0.2 and 0.5, respectively. The results of OSATS score variation and confidence level between T2 and T4 are displayed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eVariation of confidence level between T1 and T5, and OSATS score between T2 and T4\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=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStage\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eConfidence scale (out of 10)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eT1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e2.25\u0026thinsp;\u0026plusmn;\u0026thinsp;1.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eT5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e5.24\u0026thinsp;\u0026plusmn;\u0026thinsp;2.21\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eOSATS TS (out of 16)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eT2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e3.5\u0026thinsp;\u0026plusmn;\u0026thinsp;2.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eT4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e7.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eOSATS NTS (out of 16)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eT2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e6.5\u0026thinsp;\u0026plusmn;\u0026thinsp;2.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eT4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e9.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1\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\u003eAt the end of T4, the average rating given to the simulation training by the interns was 3.8/5. The majority (98.6%) recommend the training to other interns. The results of the final questionnaire are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\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\u003eSummary of the participants' final assessment of the CTI exercise\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=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDomain\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eResponse\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSatisfaction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eVery good\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e94.50%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGood\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5.50%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eQuality of training\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eVery good\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e90.50%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGood\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9.50%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eResponse to the participants' needs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eVery good\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e65\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e87.80%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGood\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12.20%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eUsefulness of skills acquired in daily practice\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e96%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNon\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eRecommendation of the exercise to other trainees\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e73\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e98.60%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1,4%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eMin\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003eMax\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOverall rating for this training (from 1 to 5):\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3,8 (0,5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHow satisfied are you? (from 1 to 5):\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3,7 (0,4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHow well did the presenter explain the objectives? (1 to 5):\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4,2 (0,5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHow do you rate the duration of the training? (from 1 to 5):\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3,2 (1,1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5\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\u003eUnivariate and multivariate statistical analysis was then conducted to find a correlation between confidence levels and OSATS scores at the end of the simulation, in relation to certain independent variables. It was found that women had higher confidence levels than men but without impact on OSATS scores. Also, students with higher grade averages in the internship exams had higher confidence levels and technical skills identical to students with lower averages. Finally, the internship year has no impact on confidence levels or OSATS scores. The results are detailed in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCorrelation between demographic factors and the confidence level, OSATS-TS, and OSATS-NTS at the end of training\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"9\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePopulation\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eN (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eConfidence \u003c/p\u003e\u003cp\u003elevel (out of 10)\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eOSATS-TS \u003c/p\u003e\u003cp\u003e(out of 16)\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eOSATS-NTS \u003c/p\u003e\u003cp\u003e(out of 16)\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e35 (47.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e7.26\u0026thinsp;\u0026plusmn;\u0026thinsp;1.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e\u003cp\u003e11.6\u0026thinsp;\u0026plusmn;\u0026thinsp;2.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c8\"\u003e\u003cp\u003e11.5\u0026thinsp;\u0026plusmn;\u0026thinsp;3.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e37 (50%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e8.26\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e\u003cp\u003e11.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c8\"\u003e\u003cp\u003e11.06\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003ePGY\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e42 (56.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e7.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e\u003cp\u003e11.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c8\"\u003e\u003cp\u003e12.56\u0026thinsp;\u0026plusmn;\u0026thinsp;2.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e32 (43.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e7.98\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e\u003cp\u003e12.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c8\"\u003e\u003cp\u003e10\u0026thinsp;\u0026plusmn;\u0026thinsp;3.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eGrades during internship exams\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;70/100\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e19 (25.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e8.1\u0026thinsp;\u0026plusmn;\u0026thinsp;2.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e\u003cp\u003e11.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c8\"\u003e\u003cp\u003e10.6\u0026thinsp;\u0026plusmn;\u0026thinsp;2.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;70/100\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e55 (74.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e7.42\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e\u003cp\u003e11.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c8\"\u003e\u003cp\u003e12.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0.2\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\u003eIn multivariate analysis, PGY1s were more likely associated with reduced improvement in OSATS scores between T2 and T4 than PGY2s (OR\u0026thinsp;=\u0026thinsp;0.91; 95% CI: 0.81\u0026ndash;0.99; p\u0026thinsp;=\u0026thinsp;0.04). Similarly, lower levels of confidence reported at T1 were independently associated with reduced improvement of OSATS scores between T2 and T4 (OR\u0026thinsp;=\u0026thinsp;0.93; 95% CI: 0.79\u0026ndash;0.97; p\u0026thinsp;=\u0026thinsp;0.01). However, grade averages during internship year (OR\u0026thinsp;=\u0026thinsp;1.30; 95% CI: 0.98\u0026ndash;2.46; p\u0026thinsp;=\u0026thinsp;0.60) and female sex were not significantly associated with changes in OSATS scores between T2 and T4. These results are shown in Table \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePredictive factors for OSATS score increase between the first and second simulation\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\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=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003eUnivariate analysis\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e\u003cp\u003eMultivariate analysis\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOdds Ratio\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e95%- confidence interval\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eOdds Ratio\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e95%- confidence interval\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003ep\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eFirst year of internship\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.95\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.86\u0026ndash;1.10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.91\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.81\u0026ndash;0.99\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.04\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGrade averages during \u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003einternship exams\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1.41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.79\u0026ndash;3.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.98\u0026ndash;2.46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eFemale sex\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.95\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.89\u0026ndash;1.30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.93\u0026ndash;1.41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.97\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ereduced initial level of confidence\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.92\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.89\u0026ndash;1.10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.79\u0026ndash;0.97\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e0.01\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study examines intern capabilities during their first residency years when encountering a new invasive technique, identifying factors that can predict their improvement, exploring methods to enhance practical, hands-on medical education, and emphasizing the value of simulation sessions before performing invasive procedures on patients.\u003c/p\u003e\u003cp\u003eThe increase in confidence levels, and improvement of OSATS scores after a detailed procedural debriefing can indicate that interns may improve their skills with adequate practice, even if on a simulator model rather than a real patient, similar to a 2016 study by L\u0026eacute;ger et al. which showed that simulation-based training models with didactic lectures improved the success rate of chest tube insertions when compared to lecture based learning methods alone \u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. However, the statistical insignificance, with a p-value of 0.3 for confidence levels, 0.2 for TS and 0.5 for NTS may indicate the need for reassessment with a larger population size that includes a diverse array of residents from various medical and surgical specialties, as done in a 2020 study by Bevilacqua et al. which showed that introducing simulation sessions for incoming surgical residents of various subspecialties significantly improved confidence and self-efficacy during invasive procedures \u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eA 2020 study by Tawfik et al. looked into the efficiency of simulation sessions, as opposed to traditional didactic learning, in medical students while considering their interest and attentiveness, concluding that while the efficacy of simulations is very similar to those of lecture based learning, students had more positive opinions towards simulations regarding their motivation to learn, ability to practice, and overall satisfaction \u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. Similarly, when looking into participant satisfaction with the use of debriefing and simulation sessions for procedure and technical education, a score of 3.8/5 indicates a high level of satisfaction. This may be an indication that live-teaching and hands-on learning, even on simulated models, increases student attention, promotes participation and improvement of technique, and advances technical skills that are essential and lifesaving during patient interactions. However, many factors can come into play when assessing satisfaction. The presence of the educator, while participants fill the survey may push towards more positive responses as a show of respect towards the educator. The proximity of the feedback directly after completion of the simulation session may cause emotional liability and limit the time to fully consider each response. While these factors are theoretical and may be unavoidable, it is important to identify such confounding variables when analyzing the study\u0026rsquo;s impact.\u003c/p\u003e\u003cp\u003eWhen performing the univariate and multivariate analysis, the identification of postgraduate year and initial confidence level were the only predictive variables to significantly affect OSATS scores, with interns at the PGY1 level or those with lower initial confidence levels having reduced OSATS score variations and thus reduced levels of improvement with simulation and debriefing sessions, similar to a 2019 study by Liepert et al. which showed that younger interns were more likely to have reduced variations in improvement as compared to their older counterparts, who were more likely to master the technique and report reduced anxiety and increased confidence by PGY2 \u003csup\u003e14\u003c/sup\u003e. While the increased experience of a PGY2 over a PGY1 intern is an undeniable variable in evaluating score improvement, the variable of confidence levels affecting the variations in OSATS scores may identify the importance of confidence when performing medical procedures, and that lower levels of confidence, even with increased practice or advanced knowledge, may significantly hinder optimal medical care, especially during invasive procedures such as CTI. While this study shows the significance of confidence in performing invasive procedures, this idea must be reassessed with larger populations, possibly with stratifying based on level of PGY, to properly identify the roots of lower confidence levels, reducing possible confounding variables, and how the medical education systems worldwide can boost self-confidence and practical skills from earlier in the medical education programs.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe use of simulations and models has been proven to be efficient and essential tools for improving technical skills relating to CTIs. This study also identifies confidence as a significant variable towards improving hands-on skills relating to CTIs, opening future possibilities of research into the effects of confidence on other invasive procedures. Medical schools and residency programs can find ways to improve confidence levels earlier during the medical education pathway, while maintaining high standards of education in medical knowledge and patient contact, to ensure advancements in the medical fields and promote higher standards of care.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eOR: Odds Ratio; CTI: Chest Tube Insertion; PGY: Post Graduate Year; T: Time; OSATS: Objective Structured Assessment of Technical Skill; TS: Technical Skills; NTS: Non-technical Skills; SD: Standard Deviation.\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eHuman Ethics and Consent to Participate:\u003c/strong\u003e This study was initially approved by the IRB team in the university of USEK. The study was supervised thoroughly in order to adhere to the Helsinki Declaration. Informed consent was gained from each participant during study explanation and prior to starting.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Publish\u003c/strong\u003e: gained from each participant during study explanation and prior to starting.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e Data is available upon request from the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests:\u003c/strong\u003e None\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e: M.A. initiated the study and supervised all aspects of data collection. He is the primary author. R.T.S. wrote the article with M.A. and analyzed the data during and after collection. P.R. and R.K. supervised and confirmed the procedures were done ethically and to standard. Both also assisted in article writing and data collection\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e None\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGhazali D, Ilha-Schuelter P, Barbosa S, et al. Interdisciplinary teamwork for chest tube insertion and management: an integrative review. \u003cem\u003eAnaesthesiol Intensive Ther\u003c/em\u003e. 2021;53(5):456-465. doi:10.5114/ait.2021.111349\u003c/li\u003e\n\u003cli\u003eFilosso PL, Guerrera F, Sandri A, et al. Errors and Complications in Chest Tube Placement. \u003cem\u003eThorac Surg Clin\u003c/em\u003e. 2017;27(1):57-67. Doi: 10.1016/j.thorsurg.2016.08.009\u003c/li\u003e\n\u003cli\u003eReview Comittee for Emergency Medicine. Emergency Medicine Defined Key Index Procedure Minimums. Published online 2017.\u003c/li\u003e\n\u003cli\u003eDeilamy I, Amini M, Abbasi HR, Bolandparvaz S, Paydar S. Impact of Peer-Assisted Learning in Chest Tube Insertion Education on Surgical Residents. \u003cem\u003eBull Emerg Trauma\u003c/em\u003e. 2022;10(2):83-86. doi:10.30476/BEAT.2022.94348.1336\u003c/li\u003e\n\u003cli\u003eTokuno J, Valanci-Aroesty S, Uchino H, et al. Teaching Chest Tube Insertion by Blended Learning: A Multi-Dimensional Analysis. \u003cem\u003eSurg Innov\u003c/em\u003e. 2024;31(1):92-102. doi:10.1177/15533506231211049\u003c/li\u003e\n\u003cli\u003eBerger M, Weber L, McNamara S, Shin-Kim J, Strauss J, Pathak S. Simulation-Based Mastery Learning Course for Tube Thoracostomy. \u003cem\u003eMedEdPORTAL\u003c/em\u003e. 2022; 18:11266. doi:10.15766/mep_2374-8265.11266\u003c/li\u003e\n\u003cli\u003eIng L, Cheng A, Lin Y. Debriefing for Simulation-Based Medical Education: A Survey from the International Network of Simulation-Based Pediatric Innovation, Research and Education. \u003cem\u003eSimul Healthc\u003c/em\u003e. 2022;17(1):1-6. doi:10.1097/SIH.0000000000000541\u003c/li\u003e\n\u003cli\u003eBarsuk JH, Cohen ER, Williams MV, et al. Simulation-Based Mastery Learning for Thoracentesis Skills Improves Patient Outcomes: A Randomized Trial. \u003cem\u003eAcad Med\u003c/em\u003e. 2018;93(5):729-735. doi:10.1097/ACM.0000000000001965\u003c/li\u003e\n\u003cli\u003eVijayakumar B, Hynes G, Kitt J, Millette S, FitzPatrick M. An effective procedure skills training programme for GIM registrars. \u003cem\u003eFuture Healthc J\u003c/em\u003e. 2021;8(1): e117-e122. doi:10.7861/fhj.2020-0090\u003c/li\u003e\n\u003cli\u003eMartin JA, Regehr G, Reznick R, et al. Objective structured assessment of technical skill (OSATS) for surgical residents. \u003cem\u003eBr J Surg\u003c/em\u003e. 1997;84(2):273-278. doi:10.1046/j.1365-2168.1997. 02502.x\u003c/li\u003e\n\u003cli\u003eL\u0026eacute;ger A, Ghazali A, Petitpas F, Gu\u0026eacute;chi Y, Boureau-Voultoury A, Oriot D. Impact of simulation-based training in surgical chest tube insertion on a model of traumatic pneumothorax. \u003cem\u003eAdv Simul (Lond)\u003c/em\u003e. 2016 ;1:21. doi:10.1186/s41077-016-0021-2\u003c/li\u003e\n\u003cli\u003eBevilacqua LA, Simon J, Rutigliano D, et al. Surgical boot camp for fourth-year medical students: Impact on objective skills and subjective confidence. \u003cem\u003eSurgery\u003c/em\u003e. 2020;167(2):298-301. doi:10.1016/j.surg.2019.06.041\u003c/li\u003e\n\u003cli\u003eTawfik MMR, Fayed AA, Dawood AF, Al Mussaed E, Ibrahim GH. Simulation-Based Learning Versus Didactic Lecture in Teaching Bronchial Asthma for Undergraduate Medical Students: a Step Toward Improvement of Clinical Competencies. \u003cem\u003eMed Sci Educ\u003c/em\u003e. 2020;30(3):1061-1068. doi:10.1007/s40670-020-01014-y\u003c/li\u003e\n\u003cli\u003eLiepert AE, Velic AJ, Rademacher B, et al. Proficiency development for graduating medical students, using skills-level\u0026ndash;appropriate mastery learning versus traditional learning for chest tube placement: Assessing anxiety, confidence, and performance. \u003cem\u003eSurgery\u003c/em\u003e. 2019;165(6):1075-1081. doi:10.1016/j.surg.2019.01.015\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Simulation, Confidence, Chest tube insertion, invasive procedure, technical skills","lastPublishedDoi":"10.21203/rs.3.rs-7171613/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7171613/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective\u003c/strong\u003e: This study aims to assess the efficiency of impact simulation models on surgical resident’s skill and confidence to perform chest tube insertion\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDesign\u003c/strong\u003e: This study deployed both questionnaires to assess textbook and medical knowledge relating to chest tube insertions, and simulation models to assess technical skills required for adequate insertion. Both parts of the study were done before and after a lecture-based debriefing session was done to evaluate the improvement of the participants with both traditional lecture-based and simulation learning.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSetting\u003c/strong\u003e: This study was done at the simulation center in the University of Kaslik, Lebanon\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParticipants\u003c/strong\u003e: 74 surgical residents from postgraduate years 1 and 2 were recruited into the study, and were randomly assigned into one of six groups to undergo a simulation session divided into six stages\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: Prior to the debriefing session, the reported confidence level was 2.25±1.25, the technical skills score was 3.5±2.9 out of 16 and the nontechnical skills score was 6.5±2.5 out of 16. After a debriefing session, the reported confidence level increased to 5.24±2.21, the technical skills score increased to 7.8±1.3 and the nontechnical skills score increased to 9.7±1.1. Older postgraduate year, and higher initial confidence were found to significantly improve technical and nontechnical skills scores (OR = 0.91; 95% CI: 0.81–0.99; p = 0.04 and OR = 0.93; 95% CI: 0.79–0.97; p = 0.01, respectively)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: Exposure to invasive procedures such as chest tube insertions can be given efficiently when incorporating traditional lecture-based learning with simulation models for hands-on experience, especially in the scarcity of patients requiring such a procedure. Furthermore, the importance of building confidence in medical students and residents must be studied further to improve medical education and patient care.\u003c/p\u003e","manuscriptTitle":"Impact of simulator-based chest tube insertion training on surgical residents’ confidence and technical proficiency","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-11 15:11:27","doi":"10.21203/rs.3.rs-7171613/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"72b5692c-f357-436b-864d-faf3d2e99102","owner":[],"postedDate":"September 11th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-11-07T07:08:57+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-11 15:11:27","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7171613","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7171613","identity":"rs-7171613","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}