Contribution of Simulation-Based Learning in Advanced Cardiopulmonary Resuscitation for Undergraduate Medical Students

Contribution of Simulation-Based Learning in Advanced Cardiopulmonary Resuscitation for Undergraduate Medical Students | 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 Contribution of Simulation-Based Learning in Advanced Cardiopulmonary Resuscitation for Undergraduate Medical Students Sondes Laajimi, Haifa Bradai, Rabeb Mbarek, Nabil Chebbi, Omar Mastouri, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4411571/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 Background Healthcare simulation has become a crucial pedagogical technique across various medical disciplines.This approach use, virtual reality, or standardized patients to replicate clinical scenarios, has proven vital in preparing medical students for high-risk situations, ensuring the safety and effectiveness of critical patient management through the acquisition of technical skills, teamwork, and the ability to handle exceptional scenarios. Aims of this study wereto evaluate the theoretical knowledge of students before and after the simulation-based training (SBT) of the "Advancedcardiopulmonary resuscitation(CPR)" module, to assess their technical and non-technical skills and to describe their satisfaction. Methods This study, conducted at the Faculty of Medicine in Sousse, Tunisia, sought to objectively evaluate the impact of SBT on the theoretical knowledge, technical skills, and non-technical competencies of graduate Medical Students, during their advanced (CPR) training. The researchers employed a pre-experimental design, assessing students before and after the simulation-based workshops covering various CPR-related topics. Results We have demonstrated that the SBT was highly valued by the learners and led to significant improvements in their theoretical knowledge,There is a positive correlation between the pre and post-test score, with a correlation coefficient of r = 0.474, p < 0.0001, r² = 0.245. For technical skills, (69.8%) have improving their external cardiac massage (ECM) technique by the exam day, while 14 (16.3%) exhibited a decline (p < 0.001).Additionally, "non-technical skills"( NTS) were assessed using the Anesthesia Non-Technical Skills(ANTS) scoreamong these students, 85 (89.5%) improved their scores, while 10 (10.5%) maintained their initial score (p < 0.001).At the end of the training sessions, a strong statistically significant correlation was found between the sum of post-test scores, ANTS score, cardiac massage score, and the final score of the simulated practical “ECOS” exam (r = 0.762, p < 0.001, r²=0.581).Student satisfaction was evaluated; overall, students' impressions were predominantly excellent in over 50% of responses. Conclusion The study's contribution to the growing body of evidence supporting the integration of simulation-based learning in the formative years of medical education is particularly noteworthy. Simulation can accelerate skill acquisition and enhance the transition of knowledge and self-confidence when faced with real-life critical scenarios. Simulation Medical students Education Undergraduate cardiopulmonary resuscitation Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Background Healthcare simulation is a crucial pedagogical technique across various fields in healthcare. In 2012, the French Health Authority (HAS) defined healthcare simulation as the use of equipment, virtual reality, or standardized patients to replicate healthcare situations, aiming to teach diagnostic and therapeutic procedures, repeat medical processes, and make decisions. This approach has become vital in teaching high-risk medical disciplines, ensuring the safety and effectiveness of managing critical patients through learning technical skills, team interaction, and endless replication of exceptional scenarios. Simulation provides a risk-free learning environment for both patients and learners, facilitating the development of cognitive, technical, and human aspects. It is linked to enhancing learners' knowledge and skills, thereby improving patient outcomes. To assess the impact of simulation-based training HAS recommends referring to the "Kirkpatrick" model, which evaluates pedagogical effectiveness based on changes in learner behavior across four levels.In France, healthcare simulation is gaining ground in both continuing and initial medical education, leading to the creation of structured Objective Structured Clinical Examinations (OSCEs) for medical students. The medical education reform at the Faculty of Medicine in Sousse (Tunisia) since 2016 focused on skills and learner-centered approaches, integrating active pedagogical methods like simulation, Case-Based Learning (CBL), and Team-Based Learning (TBL). An evaluation of these new learning methods is imperative. Additionally, the Advanced Cardio-Pulmonary Resuscitation (CPR) module is delivered using simulation techniques to third-year students in the second- cycle of medical education (SCME 3) within the Community Medicine 2 curriculum. A study was conducted to assess the pedagogical impact of this learning method, based on the Kirkpatrick model (levels 1 and 2), dedicated to SCME 3 students at the Faculty of Medicine in Sousse for the academic year 2022–2023. The study objectives include evaluating theoretical knowledge and technical/non-technical skills of students before and after simulation-based learning of the "Advanced CPR" module, along with describing student satisfaction levels with this training. Methods Study Type: A pre-experimental study was carried out at the Faculty of Medicine in Sousse, at the start of the 2022-23 academic years, focusing on the teaching of the “cardiopulmonary resuscitation” (CPR) module to SCME 3rd students at the end of their clerkship year. Study Population: All SCME3 students present during the CPR Block in the academic year 2022–2023 were included. The students were divided into 5 groups by the faculty administration, with approximately 40 students per group distributed across two training centers. Each group underwent hybrid simulation training using low-fidelity mannequins. We included all medical students enrolled in SCME3 at the Faculty of Medicine in Sousse who were present during the CPR training and those authorized to take the exam. We excluded students who were absent during the pre-test post-test,or exam. Training Process The training program consisted of practical simulation workshops conducted over two days. All students underwent pre and post-tests to gauge their knowledge levels. Two groups were randomly selected for evaluation of non-technical skills using the ANTS score and a technical skill assessment involving (ECM). The workshops covered various topics: Workshop 1: Basic Life Support (BLS) and Defibrillation.Workshop 2: Management of critically ill patients using the ABCDE approach.Workshop 3: Airway management.Workshop 4: ECG monitoring and recognition of rhythms/tachycardia and bradycardia algorithms.Workshop 5: Shockable rhythms and Post-Cardiac Arrest Resuscitation.Workshop 6: Non-shockable rhythms and Decision to stop resuscitation.Workshop 7: Special circumstances related to cardiac arrest. For each group; STEP 1 : Introduction, CPR module objectives review, workshopobjectives overview, and pre-test with MCQs to assess theoretical prerequisites. STEP 2 : Practical training through workshops, with evaluation of technical skill (ECM) for selected groups and assessment of non-technical skills using the ANTS score ( 7 )during Case-Teach sessions. STEP3 : Evaluation at the end of the day with a theoretical exam (Post-Test) and a practical exam (Clinical Scenario) for all students, including assessment of NTS using the ANTS score and ECM for selectedgroups.Learner satisfaction with the simulation-based learning method was measured through a satisfaction survey. Measurement instrument We utilized three validated measurement instruments following Kirkpatrick's evaluation model( 5 ), which delineates four levels of training assessment. Level 1 - Reaction: Assessment of learner satisfaction using an institutionally validated girdbythe Sousse Medical Simulation Center(CESIM). Level 2 - Learning:Employment of a self-administered medical questionnaire to assess learners' prerequisite knowledge. Evaluation grid for technical and non-technical skills. Level 3 - Behavior: Evaluation grid for (ECM) technique validated by the Nancy Medical Simulation Center (CUESIM) RESCAPE-CM( 8 ).These instruments facilitate a comprehensive evaluation of various training aspects, ranging from learner satisfaction to knowledge and skill acquisition, behavior, and practical application of taught skills. Level 4-outcome, allows for assessing the influence of simulation-based training on patient care. However, in our study, evaluating levels 3 and 4 was impractical due to the lack of a practical placement associated with the CPR block, which would have enabled us to observe our learners in their actual work settings. Data Analysis: Data analysis was conducted using the SPSS program.For descriptive study: the normality of variable distribution was checked using the Kolmogorov-Smirnov test. Continuous variables following a normal distribution were expressed by their means and standard deviations, while categorical variables were presented by their proportions. For univariate analysis, means were compared using the student’s t-test and independent samples test, and percentages were compared using the Chi-square test.Pearson correlation was used to explore correlations between continuous variables of interest.ANOVA test was employed to compare mean scores among different student groups.A significance level of p < 0.05 was considered significant. Ethical Considerations the questionnaire response was obtained after individual candidates provided oral consent, as well as institutional authorization. Results *Population Demographicscharacteristics :In this study, a cohort of 264 third year SCME students was divided into 5 groups. After excluding 21 students from the analysis, a total of 243 students were included. The average age of the population was 23.6 (± 0.7) years, ranging from 22 to 28. The gender distribution comprised 192 females (73%) and 71 males (27%). Each group consisted of 53 students except for group A, which had 52 students.( Table I: Distribution by Groups ) Table I: Distribution by Groups Name of group Number (n) A 52 B 53 C 53 D 53 E 53 *Learning Evaluation (Kirkpatrick Level 2)of Theoretical Training (Assessment of "Knowledge") Before and After the Training: Pre-test and Post-test Scores: This questionnaire consists of 14 questions with taxonomic levels ranging from 1 to 3 as per the specification table. We assigned a score out of 20 to each student. The median pre-test score was 9.5 [7.75–12], and the median post-test score was 13 [11.5–14.75]. Thisdifference was statistically significant (p < 0.0001).At the end of the CPR training day, 205 students (84.4%) improved their scores, 26 (10.7%) showed a decline, and 12 (4.5%) maintained the same initial score. The scores for the different groups are summarized in the following table.Four questions were at a taxonomic level 3, appearing in the exam in the form of multiple-choice questions or short-answer questions; The lack of improvement in the learning curve for level 3 taxonomic questions negatively impacts the enhancement of theoretical knowledge, with a statistically significant difference (p = 0.0001). (Table II: Pre-test and Post-test Scores by Group ) Table II: Pre-test and Post-test Scores by Group Groups Médiane [IIQ] Pre-test Post- test A 14 [12.31–15.37] 14.25 [12.62–15.5] B 9.6 [8.3–11.18] 12.75 [11.68 -15] C 9 [11.5–8] 13.75 [1.68–15.56] D 9 [6.9–10] 13 [11.5–14.56] E 7.75 [6.12–9] 11 [10–12.75] There is a positive correlation between the pre-test score and the post-test score, with a correlation coefficient of r = 0.474, p < 0.0001, r² = 0.245. ( Fig. 1 : Scatter plot of Post-test Scores based on Pre-test Scores) Table III: Influence of Level 3 Taxonomic Questions on the Evolution of Theoretical Knowledge Variable score of post test P improvement Not improvement Q2 improvement 48 (23.4) 1 (2.6) 0.003 Not improvement 157 (7.6) 37 (97.4) Q8 improvement 85 (41.5) 6 (15.8) 0.003 Pas d’amélioration 120 (58.5) 32 (84.2) Q11 improvement 59 (28.8) 3 (7.9) 0.007 Not improvement 146 (71.2) 35 (92.1) Q14 improvement 115 (56.4) 11 (28.9) 0.002 Not improvement 89 (43.6) 27 (71.1) sum improvement 150 (7.5) 11 (28.9) 0.0001 Not improvement 54 (26.5) 27 (71.1) Total 205 (100%) 38 (100%) There is a positive correlation between the post-test score and the sum of reasoning question scores, with a correlation coefficient of r = 0.630, p < 0.0001, r²= 0.397. (Table III: Influence of Level 3 Taxonomic Questions on the Evolution of Theoretical Knowledge; Figure 2 : Scatter plot of Post-test Scores based on the Sum of Reasoning Questions) .However, we found a minimal but statistically significant correlation between the sum of scores for level III reasoning questions and the score on the simulation exam. (r = 0.256, p < 0.001, r² = 0.066) ( Fig. 3 : Scatter plot of Simulated Practice Scores based on the Sum of Reasoning Questions) *Evaluation of technical and non-technical learning (assessment of "skills/behavior") before and after the training We randomly selected two groups, Group D (N = 49) and Group E (N = 37), to assess technical and non-technical skills. The evaluation of (ECM) technique involved assigning initial and final scores during the learning session and final exam, respectively. The median initial score was 11[9–12], and the median final score was 12 [10.75–13]. Notably, 12 (14%) of both groups showed excellent technique initially, with 60 (69.8%) improving their CPR technique by the exam day, while 14 (16.3%) exhibited a decline. Additionally, NTS were assessed using the ANTS score, with an initial average of 6.4 (± 1.7) at the start of training and an average of 10.2 (± 2.5) on the exam day. Among these students, 85 (89.5%) improved their scores, while 10 (10.5%) maintained their initial score. ( Fig. 4 : Evolution of the score for cardiac massage; Fig. 5 : Evolution of the ANTS score during technique during the training) *Evaluation of simulated practice (simulation scenario) :At the end of the training sessions, students from 5 groups participated in a practical exam at "ECOS" stations, alternating between roles as "first responders" and "teammembers." Assessment of both technical and non-technical skills occurred during these rotations using consistent criteria from the initial training. Subsequently, all groups underwent a final simulated practice exam, evaluating students on knowledge, skills, and behavior based on a detailed assessment grid. The median score was 16[15–18], with group scores detailed in the accompanying table. ( Table IV: Simulation practice Score by Group) Table IV: Simulation practice Score by Group Groups Médiane [IIQ] A 16 [15–18] B 15.75[14,75–17] C 17 [16–18] D 17[15–18,5] E 15[14–18] We found a statistically significant difference (p < 0.05) when comparing scores across different assessments based on the order of group rotation. Group A appears to have the highest scores compared to the other groups. ( Fig. 6 : Box plot of Simulation practice Scores by Groups; Table V: Comparaison by Group) Table V: Comparaison by Group Groups Pré-test Post-test Simulationpractice score A 14 14.25 16 B 9.62 12.75 15.75 C 9 13.75 17 D 9 13 17 E 7.75 11 15 p < 0,0001 < 0,0001 0,012 A strong statistically significant correlation was found between the sum of post-test scores, ANTS score, cardiac massage score, and the final score of the simulated practical “ECOS” exam (r = 0.762, p < 0.001, r²=0.581). ( Fig. 7 : Scatter plot of simulated practice score based on the sum of knowledge questions, technical, and non-technical skills scores) *Student Satisfaction Evaluation (Kirkpatrick Level 1) At the end of the CPR module, student satisfaction was evaluated using an institution-validated evaluation grid consisting of 44 items covering the Introduction to the module and provided materials, Equipment, Scenario quality, Debriefing, and Instructors. A total of 211 completed evaluation forms were collected after eliminating any improperly filled or incomplete forms.Overall, students' impressions were predominantly excellent in over 50% of responses. Approximately 77% found the materials provided before the training session to be good to excellent. Regarding the overall assessment of the simulation room, around 88% rated it as good to excellent.87% of students acknowledged the scenario's ability to promote attitudes and behaviors as good to excellent. 86% of students considered the debriefing at the end of the scenario as constructive, with over 90% appreciating its overall quality.The overall quality of instructors' work was rated as good to excellent by more than 91% of students. The responses to this questionnaire are summarized in the following table.( Table VI: Evaluation of student satisfaction towards the CPR module. Discussion Our study, conducted at the Faculty of Medicine in Sousse (Tunisia), aimed to evaluate the "CPR" module taught to SCME 3 students through a simulation-based learning approach during the academic year 2022-2023and objectively demonstrate that Simulation is also applicable for medical students during their formative years of learning and gaining health professional skills. Given that the student may not have the chance to participate in a real resuscitation scenario, simulation can be used to accelerate skills acquisition and enhance the transition of knowledge and self-confidence when faced with a real situation. The objective was to assess the theoretical knowledge, as well as the technical and non-technical skills of SCME 3 students before and after this training. The results, consistent with numerous other studies( 1 )( 9 ), showed that simulation-based training in critical patient scenarios was highly valued by learners, leading to a significant improvement in theoretical, technical, and non-technical knowledge, even at higher taxonomic levels. Simulation is considered an essential tool for learning, promoting reflection, conceptualization, and transferability of skills( 4 ).Simulation is a crucial tool for engaging and high-quality learning, facilitating the acquisition of new knowledge, skill development, and attitude change among learners. Simulation has been shown to be more effective than traditional lecture-based format, it also allows for the translation of theory into practice and decision making in complex clinical situations. Assessing learner satisfaction is vital for ensuring quality learning, but it should be complemented by theoretical and practical evaluations. Simulation-based learning showed a significant improvement in theoretical knowledge and technical and non-technical skills of students, particularly in questions requiring complex reasoning ( 10 )( 11 )( 12 )( 13 ).Several studies have highlighted the effectiveness of simulation in teaching technical skills, especially in emergency medicine and anesthesia-resuscitation ( 13 ). Simulation on mannequins allows practice of common procedures like external cardiac massage and rare procedures like cricothyroid puncture or thoracostomy ( 3 )( 9 ). This pedagogical method has proven effective in practical skill acquisition, particularly for managing cardiac arrest, which requires mastery of various technical skills( 14 ). The reasons for its wide scale implementation are its ability to provide standardized education, an optimal educational environment, patient safety, enhancement of professional competence and skills, error reduction, retention, and reproducibility. Technical and non-technical skills(NTS) are closely linked to healthcare simulation, with non-technical skills encompassing relational and communication aspects that are more challenging to evaluate( 15 ). In our study, assessment of non-technical skills utilized the ANTS scale, comprising 4 items and 15 detailed elements describing specific behaviors( 16 ). Simulation goes beyond teaching technical skills; it immerses learners in real-life scenarios to develop teamwork, communication, and leadership. Non-technical skills (NTS) are essential competencies for healthcare professionals, in addition to technical skills. These include communication, teamwork, leadership, decision-making, stress management, and others. Mastering NTS is crucial to ensure patient safety. However, traditional teaching methods have long focused on technical skills, neglecting NTS. This is where medical simulation comes into( 12 )play for medical students. According to the studies presented; simulation offers many advantages for the development of NTS in medical students like, training in communication and teamwork during simulated crisis scenarios( 17 ).This allows students to rehearse high-risk situations in a safe environment, occurs development of leadership and decision-making skills through assigned leadership roles during simulations( 18 ). Students learn to manage stress and make informed decisions.Integration of NTS with technical skills in high-fidelity simulations. This better reflects the reality of medical practice( 19 ). Many studies show that simulation significantly improves NTS in medical students, with apositive impact on patient safety. This is why medical schools are increasingly integratingsimulation, in addition to traditional methods. Simulation also has its limitations in terms of cost and implementation. But its contribution to developing competent future physicians who are mindful of patient safety is undeniable.Simulation is a powerful tool for teaching and evaluating NTS in medical students. Its growing use in medical education attests to its importance for the future of our healthcare systems. Our study demonstrated a significant improvement in students' non-technical skills on the exam day. Simulation enhances communication among healthcare professionals and between them and patients, especially in sensitive situations like delivering bad news ( 20 ). It also enhances crisis resource management skills and interdisciplinary communication ( 21 ).Simulation, likened to flight simulators for pilots, plays a crucial role in practical learning in medicine and healthcare, offering diverse educational opportunities even with limited resources. Its integration in medical education enhances licensing and certification processes, ultimately improving the overall quality of patient care. Our study was the firstat our institution to evaluate the relationship between simulation and both theoretical and practical knowledge, as well as the learning curve of undergraduate medical students at different taxonomic levels. We demonstrated that simulation-based training provides medical students with a safe and controlled environment to practice advanced (CPR) techniques without putting real patients at risk.Simulation-based training has been shown to improve knowledge acquisition, decision-making, and performance compared to traditional teaching methods. StydyLimitations However, the long-term retention of skills and knowledge gained through simulation-based training is not well-established, and additional longitudinal studies are needed.Implementing high-fidelity simulation-based CPR training can be resource-intensive, requiring specialized equipment and trained facilitators, which may limit its widespread adoption. Perspective Simulation-based CPR training is a valuable and evidence-based approach to prepare undergraduate medical students for managing cardio-respiratory emergencies.Integrating simulation-based CPR training into the undergraduate medical curriculum can help bridge the gap between theoretical knowledge and practical skills, enhancing students' readiness for clinical practice. As medical education continues to evolve, the use of simulation-based learning is likely to become more prevalent, complementing traditional teaching methods and ensuring that future healthcare professionals are well-equipped to provide high-quality CPR care. Conclusion Simulation in the medical field is a crucial tool for learning, fostering systematic reflection on actions, facilitating conceptualization, and enhancing transferability. This pedagogical method comes in diverse forms, offering a range of learning experiences.The use of simulation enables the acquisition and refinement of skills like communication, teamwork, and theoretical knowledge. It plays a key role in ensuring patient safety by reducing the likelihood of errors. Particularly in acute care specialties, simulation is becoming increasingly prevalent as a method of education.The primary objective is to advance the adoption of simulation-based learning, especially among final-year medical students during their externships. This preparation equips them to effectively handle real-world scenarios they will encounter as residents during their internships.The challenge remains to evaluate Kirkpatrick’s level 3; 4. Abbreviations French Health Authority (HAS);simulation-based training (SBT); cardiopulmonary resuscitation(CPR); external cardiac massage (ECM); non-technical skill ( NTS); Anesthesia Non-Technical Skills score (ANTS score); simulated practical exam (ECOS), Structured Clinical Examinations (OSCEs); Case-Based Learning (CBL); Team-Based Learning (TBL); third-year of second- cycle of medical education (SCME 3); Sousse Medical Simulation Center(CESIM) Declarations Acknowledgments The authors would like to acknowledge all the medical trainees and to all instructors and educators of the faculty of medicine of Sousse who participated in this research and contributed their time. Ethics approval and consent to participate: The ETHIC medical committee of the faculty of the Medicine of Sousse (Comitéd’éthiquemédicale à la faculté de medecine de Sousse) in her headPrSouheil Mlayeh approved this study. Consent for publication: not applicable. Availability of data and materials: Data sets used and/or analyzed in this study are available from the corresponding author upon reasonable request. All material is the property of the authors, and/or no permission is required. Data are provided in related files Competing interests: The authors declare no conflicts of interest. Funding : No funding / Not applicable Authors' contributions: S.L and W.N wrote the main manuscript H.B . and O.M prepared the tables and figures D.L and Naou.Ch reviewed the manuscript R.M and Nab.Chreviewed the final methodology and tables. S.L is the corresponding author. References Masson E. Apport de l'apprentissage par la simulation dans l'enseignement de la pneumologie [Internet]. EM-Consulte. [cité 4 mai 2024]. 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Early acquisition of non-technical skills using a blended approach to simulation-based medical education. Adv Simul. 14 août 2017;2(1):12. Magill JC, Tolley N. Non-technical Skills Simulation Training. Curr Otorhinolaryngol Rep. 1 mars 2020;8(1):106‑10. Hawkins A, Tredgett K. Use of high-fidelity simulation to improve communication skills regarding death and dying: a qualitative study. BMJ Support Palliat Care. déc 2016;6(4):474‑8. Lee JY, Mucksavage P, Canales C, McDougall EM, Lin S. High Fidelity Simulation Based Team Training in Urology: A Preliminary Interdisciplinary Study of Technical and Nontechnical Skills in Laparoscopic Complications Management. J Urol. avr 2012;187(4):1385‑91. Additional Declarations No competing interests reported. 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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-4411571","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":308005955,"identity":"ea2671b3-764c-4527-817c-7b73305ab6bd","order_by":0,"name":"Sondes Laajimi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA90lEQVRIiWNgGAWjYJACCQYGCyB1sIEhoQJIMzM3EKNFAqrlDEgLI9FagICxDUzi1yLf3nvwxoc/EvL8jYdbNzycVxvN3w7U8qNiG04tBmfOJVvObJMwnHHgYNuNxG3Hc2ccZmxg7DlzG7cWiRwzad4GCcYGiJZjuQ1ALcyMbbi1yM8AavnzR8J+PljLnGO58wlpYbgB1MLAJpG4AayloSZ3AyEtBmfOGFv2tkkkbwRpSTh2IHcjUMtBfH6Rb+8xvPHjj43tvBvHn938UVOXO+/84YMPflTgcRgcSBwAkYfB7ANEqAcC/gYQWUec4lEwCkbBKBhRAAAMcWcFblku8AAAAABJRU5ErkJggg==","orcid":"","institution":"emergency medical service (EMS 03), university Sahloul hospitalTunisia","correspondingAuthor":true,"prefix":"","firstName":"Sondes","middleName":"","lastName":"Laajimi","suffix":""},{"id":308005956,"identity":"50f4d6c7-ae6c-4b94-98c8-1cf338bd9b08","order_by":1,"name":"Haifa Bradai","email":"","orcid":"","institution":"emergency medical service (EMS 03), university Sahloul hospitalTunisia","correspondingAuthor":false,"prefix":"","firstName":"Haifa","middleName":"","lastName":"Bradai","suffix":""},{"id":308005957,"identity":"a0977ee4-10d3-4f60-b154-967f20b0585c","order_by":2,"name":"Rabeb Mbarek","email":"","orcid":"","institution":"emergency medical service (EMS 03), university Sahloul hospitalTunisia","correspondingAuthor":false,"prefix":"","firstName":"Rabeb","middleName":"","lastName":"Mbarek","suffix":""},{"id":308005958,"identity":"56e364eb-879b-437a-bc2c-b3dacb1b605a","order_by":3,"name":"Nabil Chebbi","email":"","orcid":"","institution":"emergency medical service (EMS 03), university Sahloul hospitalTunisia","correspondingAuthor":false,"prefix":"","firstName":"Nabil","middleName":"","lastName":"Chebbi","suffix":""},{"id":308005959,"identity":"a0acdae3-9d6e-402f-9f6b-28eb96ed99ef","order_by":4,"name":"Omar Mastouri","email":"","orcid":"","institution":"emergency medical service (EMS 03), university Sahloul hospitalTunisia","correspondingAuthor":false,"prefix":"","firstName":"Omar","middleName":"","lastName":"Mastouri","suffix":""},{"id":308005960,"identity":"4a201451-528d-4f2e-9484-12537880f65a","order_by":5,"name":"Naoufel Chebili","email":"","orcid":"","institution":"emergency medical service (EMS 03), university Sahloul hospitalTunisia","correspondingAuthor":false,"prefix":"","firstName":"Naoufel","middleName":"","lastName":"Chebili","suffix":""},{"id":308005961,"identity":"cbb5ecbd-8eb3-4149-9a4d-022d3919c9cc","order_by":6,"name":"Dorra Loghmari","email":"","orcid":"","institution":"emergency medical service (EMS 03), university Sahloul hospitalTunisia","correspondingAuthor":false,"prefix":"","firstName":"Dorra","middleName":"","lastName":"Loghmari","suffix":""},{"id":308005962,"identity":"14cc1cda-6e2f-4a5c-b5fd-cb8392b2c949","order_by":7,"name":"Walid Naija","email":"","orcid":"","institution":"Department of Anesthesia and intensive care, , university Sahloul hospital","correspondingAuthor":false,"prefix":"","firstName":"Walid","middleName":"","lastName":"Naija","suffix":""}],"badges":[],"createdAt":"2024-05-13 08:01:44","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4411571/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4411571/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":57790797,"identity":"0a159812-3006-4871-8405-0f3ab3d3648e","added_by":"auto","created_at":"2024-06-05 17:26:14","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":50734,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eScatter plot of Post-test Scores based on Pre-test Scores\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Capture1.png","url":"https://assets-eu.researchsquare.com/files/rs-4411571/v1/849d36e5cb9f73d9aa362e4e.png"},{"id":57790798,"identity":"10ab8953-bc6a-4d3b-b4f5-d43dae2b640a","added_by":"auto","created_at":"2024-06-05 17:26:14","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":39035,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eScatter plot of Post-test Scores based on the Sum of Reasoning Questions\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Capture2.png","url":"https://assets-eu.researchsquare.com/files/rs-4411571/v1/310416eba419154ff58f34c3.png"},{"id":57789795,"identity":"f7808e82-e231-49f1-8fd3-8a41eb6dd70c","added_by":"auto","created_at":"2024-06-05 17:18:14","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":34686,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eScatter plot of Simulated Practice Scores based on the Sum of Reasoning Questions\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Capture3.png","url":"https://assets-eu.researchsquare.com/files/rs-4411571/v1/e852d41e97989d5e312ca543.png"},{"id":57789798,"identity":"48ce5808-d9f2-4628-9a0e-b7dbe0a4b17e","added_by":"auto","created_at":"2024-06-05 17:18:14","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":10325,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eEvolution of the score for cardiac massage\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Capture4.png","url":"https://assets-eu.researchsquare.com/files/rs-4411571/v1/b3789cd5bcc0f7d45c614864.png"},{"id":57789791,"identity":"197f9baf-8700-4c3f-a9b3-2e2527301bb3","added_by":"auto","created_at":"2024-06-05 17:18:14","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":10313,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eEvolution of the ANTS score during technique during the training\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Capture5.png","url":"https://assets-eu.researchsquare.com/files/rs-4411571/v1/849b11c9cc355d255a3d93cc.png"},{"id":57789792,"identity":"049def6c-14ec-44e3-bb43-ef82b30ca7c8","added_by":"auto","created_at":"2024-06-05 17:18:14","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":17643,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eBox plot of Simulation practice Scores by Groups\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Capture6.png","url":"https://assets-eu.researchsquare.com/files/rs-4411571/v1/8bc0a719325932809408b2b6.png"},{"id":57789797,"identity":"25ce3d53-b47b-4773-bd54-88231b453568","added_by":"auto","created_at":"2024-06-05 17:18:14","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":35867,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eScatterplot of simulated practice score based on the sum of knowledge questions, technical, and non-technical skills scores.\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Capture7.png","url":"https://assets-eu.researchsquare.com/files/rs-4411571/v1/ae627f3bce20461931910ea9.png"},{"id":95722978,"identity":"94158f91-fc6b-4a42-9e76-2f29fc54d81a","added_by":"auto","created_at":"2025-11-12 09:53:41","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1534980,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4411571/v1/9501f97c-3da1-4980-a3f8-19a3c9555c79.pdf"},{"id":57789790,"identity":"ff977ea5-c3ce-4327-ad80-ab373e3b691c","added_by":"auto","created_at":"2024-06-05 17:18:14","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":17424,"visible":true,"origin":"","legend":"","description":"","filename":"AdditionalTable.docx","url":"https://assets-eu.researchsquare.com/files/rs-4411571/v1/0e4a84d520ea77904850f930.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Contribution of Simulation-Based Learning in Advanced Cardiopulmonary Resuscitation for Undergraduate Medical Students","fulltext":[{"header":"Background","content":"\u003cp\u003eHealthcare simulation is a crucial pedagogical technique across various fields in healthcare. In 2012, the French Health Authority (HAS) defined healthcare simulation as the use of equipment, virtual reality, or standardized patients to replicate healthcare situations, aiming to teach diagnostic and therapeutic procedures, repeat medical processes, and make decisions. This approach has become vital in teaching high-risk medical disciplines, ensuring the safety and effectiveness of managing critical patients through learning technical skills, team interaction, and endless replication of exceptional scenarios. Simulation provides a risk-free learning environment for both patients and learners, facilitating the development of cognitive, technical, and human aspects. It is linked to enhancing learners' knowledge and skills, thereby improving patient outcomes. To assess the impact of simulation-based training HAS recommends referring to the \"Kirkpatrick\" model, which evaluates pedagogical effectiveness based on changes in learner behavior across four levels.In France, healthcare simulation is gaining ground in both continuing and initial medical education, leading to the creation of structured Objective Structured Clinical Examinations (OSCEs) for medical students. The medical education reform at the Faculty of Medicine in Sousse (Tunisia) since 2016 focused on skills and learner-centered approaches, integrating active pedagogical methods like simulation, Case-Based Learning (CBL), and Team-Based Learning (TBL). An evaluation of these new learning methods is imperative. Additionally, the Advanced Cardio-Pulmonary Resuscitation (CPR) module is delivered using simulation techniques to third-year students in the second- cycle of medical education (SCME 3) within the Community Medicine 2 curriculum. A study was conducted to assess the pedagogical impact of this learning method, based on the Kirkpatrick model (levels 1 and 2), dedicated to SCME 3 students at the Faculty of Medicine in Sousse for the academic year 2022\u0026ndash;2023.\u003c/p\u003e \u003cp\u003eThe study objectives include evaluating theoretical knowledge and technical/non-technical skills of students before and after simulation-based learning of the \"Advanced CPR\" module, along with describing student satisfaction levels with this training.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Type:\u003c/h2\u003e \u003cp\u003eA pre-experimental study was carried out at the Faculty of Medicine in Sousse, at the start of the 2022-23 academic years, focusing on the teaching of the \u0026ldquo;cardiopulmonary resuscitation\u0026rdquo; (CPR) module to SCME 3rd students at the end of their clerkship year.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStudy Population:\u003c/h2\u003e \u003cp\u003eAll SCME3 students present during the CPR Block in the academic year 2022\u0026ndash;2023 were included. The students were divided into 5 groups by the faculty administration, with approximately 40 students per group distributed across two training centers. Each group underwent hybrid simulation training using low-fidelity mannequins.\u003c/p\u003e \u003cp\u003eWe included all medical students enrolled in SCME3 at the Faculty of Medicine in Sousse who were present during the CPR training and those authorized to take the exam. We excluded students who were absent during the pre-test post-test,or exam.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eTraining Process\u003c/h2\u003e \u003cp\u003eThe training program consisted of practical simulation workshops conducted over two days. All students underwent pre and post-tests to gauge their knowledge levels. Two groups were randomly selected for evaluation of non-technical skills using the ANTS score and a technical skill assessment involving (ECM). The workshops covered various topics: Workshop 1: Basic Life Support (BLS) and Defibrillation.Workshop 2: Management of critically ill patients using the ABCDE approach.Workshop 3: Airway management.Workshop 4: ECG monitoring and recognition of rhythms/tachycardia and bradycardia algorithms.Workshop 5: Shockable rhythms and Post-Cardiac Arrest Resuscitation.Workshop 6: Non-shockable rhythms and Decision to stop resuscitation.Workshop 7: Special circumstances related to cardiac arrest.\u003c/p\u003e \u003cp\u003eFor each group; \u003cb\u003eSTEP 1\u003c/b\u003e: Introduction, CPR module objectives review, workshopobjectives overview, and pre-test with MCQs to assess theoretical prerequisites.\u003cb\u003eSTEP 2\u003c/b\u003e: Practical training through workshops, with evaluation of technical skill (ECM) for selected groups and assessment of non-technical skills using the ANTS score (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)during Case-Teach sessions.\u003cb\u003eSTEP3\u003c/b\u003e: Evaluation at the end of the day with a theoretical exam (Post-Test) and a practical exam (Clinical Scenario) for all students, including assessment of NTS using the ANTS score and ECM for selectedgroups.Learner satisfaction with the simulation-based learning method was measured through a satisfaction survey.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eMeasurement instrument\u003c/h2\u003e \u003cp\u003eWe utilized three validated measurement instruments following Kirkpatrick's evaluation model(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), which delineates four levels of training assessment. Level 1 - Reaction: Assessment of learner satisfaction using an institutionally validated girdbythe Sousse Medical Simulation Center(CESIM). Level 2 - Learning:Employment of a self-administered medical questionnaire to assess learners' prerequisite knowledge. Evaluation grid for technical and non-technical skills. Level 3 - Behavior: Evaluation grid for (ECM) technique validated by the Nancy Medical Simulation Center (CUESIM) RESCAPE-CM(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).These instruments facilitate a comprehensive evaluation of various training aspects, ranging from learner satisfaction to knowledge and skill acquisition, behavior, and practical application of taught skills.\u003c/p\u003e \u003cp\u003eLevel 4-outcome, allows for assessing the influence of simulation-based training on patient care. However, in our study, evaluating levels 3 and 4 was impractical due to the lack of a practical placement associated with the CPR block, which would have enabled us to observe our learners in their actual work settings.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis:\u003c/h2\u003e \u003cp\u003eData analysis was conducted using the SPSS program.For descriptive study: the normality of variable distribution was checked using the Kolmogorov-Smirnov test. Continuous variables following a normal distribution were expressed by their means and standard deviations, while categorical variables were presented by their proportions. For univariate analysis, means were compared using the student\u0026rsquo;s t-test and independent samples test, and percentages were compared using the Chi-square test.Pearson correlation was used to explore correlations between continuous variables of interest.ANOVA test was employed to compare mean scores among different student groups.A significance level of p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered significant.\u003c/p\u003e \u003cp\u003e \u003cb\u003eEthical Considerations\u003c/b\u003e\u003c/p\u003e \u003cp\u003e the questionnaire response was obtained after individual candidates provided oral consent, as well as institutional authorization.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e \u003cem\u003e*Population Demographicscharacteristics\u003c/em\u003e:In this study, a cohort of 264 third year SCME students was divided into 5 groups. After excluding 21 students from the analysis, a total of 243 students were included. The average age of the population was 23.6 (\u0026plusmn;\u0026thinsp;0.7) years, ranging from 22 to 28. The gender distribution comprised 192 females (73%) and 71 males (27%). Each group consisted of 53 students except for group A, which had 52 students.(\u003cb\u003eTable\u003c/b\u003e I: \u003cb\u003eDistribution by Groups\u003c/b\u003e)\u003c/p\u003e \u003cp\u003e \u003cb\u003eTable I: Distribution by Groups\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"2\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eName of group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber (n)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e52\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003cp\u003e*Learning Evaluation (Kirkpatrick Level 2)of Theoretical Training (Assessment of \"Knowledge\") Before and After the Training:\u003c/p\u003e \u003cp\u003ePre-test and Post-test Scores: This questionnaire consists of 14 questions with taxonomic levels ranging from 1 to 3 as per the specification table. We assigned a score out of 20 to each student. The median pre-test score was 9.5 [7.75\u0026ndash;12], and the median post-test score was 13 [11.5\u0026ndash;14.75]. Thisdifference was statistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001).At the end of the CPR training day, 205 students (84.4%) improved their scores, 26 (10.7%) showed a decline, and 12 (4.5%) maintained the same initial score. The scores for the different groups are summarized in the following table.Four questions were at a taxonomic level 3, appearing in the exam in the form of multiple-choice questions or short-answer questions; The lack of improvement in the learning curve for level 3 taxonomic questions negatively impacts the enhancement of theoretical knowledge, with a statistically significant difference (p\u0026thinsp;=\u0026thinsp;0.0001).\u003cb\u003e(Table II: Pre-test and Post-test Scores by Group\u003c/b\u003e)\u003c/p\u003e \u003cp\u003e \u003cb\u003eTable II: Pre-test and Post-test Scores by Group\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabb\" border=\"1\"\u003e \u003ccolgroup cols=\"3\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eGroups\u003c/span\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eM\u0026eacute;diane [IIQ]\u003c/span\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ePre-test\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003ePost- test\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14 [12.31\u0026ndash;15.37]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14.25 [12.62\u0026ndash;15.5]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9.6 [8.3\u0026ndash;11.18]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12.75 [11.68 -15]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9 [11.5\u0026ndash;8]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13.75 [1.68\u0026ndash;15.56]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9 [6.9\u0026ndash;10]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13 [11.5\u0026ndash;14.56]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7.75 [6.12\u0026ndash;9]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11 [10\u0026ndash;12.75]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThere is a positive correlation between the pre-test score and the post-test score, with a correlation coefficient of r\u0026thinsp;=\u0026thinsp;0.474, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001, r\u0026sup2; = 0.245. \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e: \u003cb\u003eScatter plot of Post-test Scores based on Pre-test Scores)\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eTable III: Influence of Level 3 Taxonomic Questions on the Evolution of Theoretical Knowledge\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabc\" border=\"1\"\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003escore of post test\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eimprovement\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNot improvement\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\u003eQ2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eimprovement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48 (23.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (2.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot improvement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e157 (7.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37 (97.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eQ8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eimprovement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e85 (41.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (15.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePas d\u0026rsquo;am\u0026eacute;lioration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e120 (58.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32 (84.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eQ11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eimprovement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59 (28.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (7.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.007\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot improvement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e146 (71.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35 (92.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eQ14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eimprovement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e115 (56.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 (28.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot improvement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e89 (43.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27 (71.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003esum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eimprovement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e150 (7.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 (28.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot improvement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e54 (26.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27 (71.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e205 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e38 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThere is a positive correlation between the post-test score and the sum of reasoning question scores, with a correlation coefficient of r\u0026thinsp;=\u0026thinsp;0.630, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001, r\u0026sup2;= 0.397.\u003cb\u003e(Table III: Influence of Level 3 Taxonomic Questions on the Evolution of Theoretical Knowledge;\u003c/b\u003eFigure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e: \u003cb\u003eScatter plot of Post-test Scores based on the Sum of Reasoning Questions)\u003c/b\u003e.However, we found a minimal but statistically significant correlation between the sum of scores for level III reasoning questions and the score on the simulation exam. (r\u0026thinsp;=\u0026thinsp;0.256, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, r\u0026sup2; = 0.066)\u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e: \u003cb\u003eScatter plot of Simulated Practice Scores based on the Sum of Reasoning Questions)\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003e*Evaluation of technical and non-technical learning (assessment of \"skills/behavior\") before and after the training\u003c/strong\u003e \u003cp\u003eWe randomly selected two groups, Group D (N\u0026thinsp;=\u0026thinsp;49) and Group E (N\u0026thinsp;=\u0026thinsp;37), to assess technical and non-technical skills.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eThe evaluation of (ECM) technique involved assigning initial and final scores during the learning session and final exam, respectively. The median initial score was 11[9\u0026ndash;12], and the median final score was 12 [10.75\u0026ndash;13]. Notably, 12 (14%) of both groups showed excellent technique initially, with 60 (69.8%) improving their CPR technique by the exam day, while 14 (16.3%) exhibited a decline. Additionally, NTS were assessed using the ANTS score, with an initial average of 6.4 (\u0026plusmn;\u0026thinsp;1.7) at the start of training and an average of 10.2 (\u0026plusmn;\u0026thinsp;2.5) on the exam day. Among these students, 85 (89.5%) improved their scores, while 10 (10.5%) maintained their initial score. \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e: \u003cb\u003eEvolution of the score for cardiac massage;\u003c/b\u003e Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e: \u003cb\u003eEvolution of the ANTS score during technique during the training)\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e*Evaluation of simulated practice (simulation scenario)\u003c/em\u003e:At the end of the training sessions, students from 5 groups participated in a practical exam at \"ECOS\" stations, alternating between roles as \"first responders\" and \"teammembers.\" Assessment of both technical and non-technical skills occurred during these rotations using consistent criteria from the initial training. Subsequently, all groups underwent a final simulated practice exam, evaluating students on knowledge, skills, and behavior based on a detailed assessment grid. The median score was 16[15\u0026ndash;18], with group scores detailed in the accompanying table. (\u003cb\u003eTable IV: Simulation practice Score by Group)\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eTable IV: Simulation practice Score by Group\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabd\" border=\"1\"\u003e \u003ccolgroup cols=\"2\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroups\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u0026eacute;diane [IIQ]\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 [15\u0026ndash;18]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15.75[14,75\u0026ndash;17]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 [16\u0026ndash;18]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17[15\u0026ndash;18,5]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15[14\u0026ndash;18]\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\u003eWe found a statistically significant difference (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) when comparing scores across different assessments based on the order of group rotation. Group A appears to have the highest scores compared to the other groups.\u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e: \u003cb\u003eBox plot of Simulation practice Scores by Groups; Table V: Comparaison by Group)\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eTable V: Comparaison by Group\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabe\" border=\"1\"\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\u003eGroups\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePr\u0026eacute;-test\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePost-test\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSimulationpractice score\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15.75\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,0001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,0001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0,012\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 \u003cp\u003e \u003c/p\u003e \u003cp\u003eA strong statistically significant correlation was found between the sum of post-test scores, ANTS score, cardiac massage score, and the final score of the simulated practical \u0026ldquo;ECOS\u0026rdquo; exam (r\u0026thinsp;=\u0026thinsp;0.762, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, r\u0026sup2;=0.581).\u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003e: \u003cb\u003eScatter plot of simulated practice score based on the sum of knowledge questions, technical, and non-technical skills scores)\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e*Student Satisfaction Evaluation (Kirkpatrick Level 1)\u003c/em\u003eAt the end of the CPR module, student satisfaction was evaluated using an institution-validated evaluation grid consisting of 44 items covering the Introduction to the module and provided materials, Equipment, Scenario quality, Debriefing, and Instructors. A total of 211 completed evaluation forms were collected after eliminating any improperly filled or incomplete forms.Overall, students' impressions were predominantly excellent in over 50% of responses. Approximately 77% found the materials provided before the training session to be good to excellent. Regarding the overall assessment of the simulation room, around 88% rated it as good to excellent.87% of students acknowledged the scenario's ability to promote attitudes and behaviors as good to excellent. 86% of students considered the debriefing at the end of the scenario as constructive, with over 90% appreciating its overall quality.The overall quality of instructors' work was rated as good to excellent by more than 91% of students. The responses to this questionnaire are summarized in the following table.(\u003cb\u003eTable VI: Evaluation of student satisfaction towards the CPR module.\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003e Our study, conducted at the Faculty of Medicine in Sousse (Tunisia), aimed to evaluate the \"CPR\" module taught to SCME 3 students through a simulation-based learning approach during the academic year 2022-2023and objectively demonstrate that Simulation is also applicable for medical students during their formative years of learning and gaining health professional skills. Given that the student may not have the chance to participate in a real resuscitation scenario, simulation can be used to accelerate skills acquisition and enhance the transition of knowledge and self-confidence when faced with a real situation.\u003c/p\u003e \u003cp\u003eThe objective was to assess the theoretical knowledge, as well as the technical and non-technical skills of SCME 3 students before and after this training. The results, consistent with numerous other studies(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e), showed that simulation-based training in critical patient scenarios was highly valued by learners, leading to a significant improvement in theoretical, technical, and non-technical knowledge, even at higher taxonomic levels. Simulation is considered an essential tool for learning, promoting reflection, conceptualization, and transferability of skills(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).Simulation is a crucial tool for engaging and high-quality learning, facilitating the acquisition of new knowledge, skill development, and attitude change among learners. Simulation has been shown to be more effective than traditional lecture-based format, it also allows for the translation of theory into practice and decision making in complex clinical situations.\u003c/p\u003e \u003cp\u003eAssessing learner satisfaction is vital for ensuring quality learning, but it should be complemented by theoretical and practical evaluations. Simulation-based learning showed a significant improvement in theoretical knowledge and technical and non-technical skills of students, particularly in questions requiring complex reasoning (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).Several studies have highlighted the effectiveness of simulation in teaching technical skills, especially in emergency medicine and anesthesia-resuscitation (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Simulation on mannequins allows practice of common procedures like external cardiac massage and rare procedures like cricothyroid puncture or thoracostomy (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). This pedagogical method has proven effective in practical skill acquisition, particularly for managing cardiac arrest, which requires mastery of various technical skills(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). The reasons for its wide scale implementation are its ability to provide standardized education, an optimal educational environment, patient safety, enhancement of professional competence and skills, error reduction, retention, and reproducibility. Technical and non-technical skills(NTS) are closely linked to healthcare simulation, with non-technical skills encompassing relational and communication aspects that are more challenging to evaluate(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). In our study, assessment of non-technical skills utilized the ANTS scale, comprising 4 items and 15 detailed elements describing specific behaviors(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Simulation goes beyond teaching technical skills; it immerses learners in real-life scenarios to develop teamwork, communication, and leadership. Non-technical skills (NTS) are essential competencies for healthcare professionals, in addition to technical skills. These include communication, teamwork, leadership, decision-making, stress management, and others. Mastering NTS is crucial to ensure patient safety. However, traditional teaching methods have long focused on technical skills, neglecting NTS. This is where medical simulation comes into(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)play for medical students. According to the studies presented; simulation offers many advantages for the development of NTS in medical students like, training in communication and teamwork during simulated crisis scenarios(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).This allows students to rehearse high-risk situations in a safe environment, occurs development of leadership and decision-making skills through assigned leadership roles during simulations(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Students learn to manage stress and make informed decisions.Integration of NTS with technical skills in high-fidelity simulations. This better reflects the reality of medical practice(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMany studies show that simulation significantly improves NTS in medical students, with apositive impact on patient safety. This is why medical schools are increasingly integratingsimulation, in addition to traditional methods.\u003c/p\u003e \u003cp\u003eSimulation also has its limitations in terms of cost and implementation. But its contribution to developing competent future physicians who are mindful of patient safety is undeniable.Simulation is a powerful tool for teaching and evaluating NTS in medical students. Its growing use in medical education attests to its importance for the future of our healthcare systems.\u003c/p\u003e \u003cp\u003eOur study demonstrated a significant improvement in students' non-technical skills on the exam day. Simulation enhances communication among healthcare professionals and between them and patients, especially in sensitive situations like delivering bad news (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). It also enhances crisis resource management skills and interdisciplinary communication (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).Simulation, likened to flight simulators for pilots, plays a crucial role in practical learning in medicine and healthcare, offering diverse educational opportunities even with limited resources. Its integration in medical education enhances licensing and certification processes, ultimately improving the overall quality of patient care.\u003c/p\u003e \u003cp\u003eOur study was the firstat our institution to evaluate the relationship between simulation and both theoretical and practical knowledge, as well as the learning curve of undergraduate medical students at different taxonomic levels. We demonstrated that simulation-based training provides medical students with a safe and controlled environment to practice advanced (CPR) techniques without putting real patients at risk.Simulation-based training has been shown to improve knowledge acquisition, decision-making, and performance compared to traditional teaching methods.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eStydyLimitations\u003c/strong\u003e \u003cp\u003eHowever, the long-term retention of skills and knowledge gained through simulation-based training is not well-established, and additional longitudinal studies are needed.Implementing high-fidelity simulation-based CPR training can be resource-intensive, requiring specialized equipment and trained facilitators, which may limit its widespread adoption.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003ePerspective\u003c/strong\u003e \u003cp\u003eSimulation-based CPR training is a valuable and evidence-based approach to prepare undergraduate medical students for managing cardio-respiratory emergencies.Integrating simulation-based CPR training into the undergraduate medical curriculum can help bridge the gap between theoretical knowledge and practical skills, enhancing students' readiness for clinical practice.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eAs medical education continues to evolve, the use of simulation-based learning is likely to become more prevalent, complementing traditional teaching methods and ensuring that future healthcare professionals are well-equipped to provide high-quality CPR care.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eSimulation in the medical field is a crucial tool for learning, fostering systematic reflection on actions, facilitating conceptualization, and enhancing transferability. This pedagogical method comes in diverse forms, offering a range of learning experiences.The use of simulation enables the acquisition and refinement of skills like communication, teamwork, and theoretical knowledge. It plays a key role in ensuring patient safety by reducing the likelihood of errors. Particularly in acute care specialties, simulation is becoming increasingly prevalent as a method of education.The primary objective is to advance the adoption of simulation-based learning, especially among final-year medical students during their externships. This preparation equips them to effectively handle real-world scenarios they will encounter as residents during their internships.The challenge remains to evaluate Kirkpatrick\u0026rsquo;s level 3; 4.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eFrench Health Authority (HAS);simulation-based training (SBT); cardiopulmonary resuscitation(CPR); external cardiac massage (ECM); non-technical skill ( NTS); Anesthesia Non-Technical Skills score (ANTS score); simulated practical exam (ECOS), Structured Clinical Examinations (OSCEs); Case-Based Learning (CBL); Team-Based Learning (TBL); third-year of second- cycle of medical education (SCME 3); Sousse Medical Simulation Center(CESIM)\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003eThe authors would like to acknowledge all the medical trainees and\u0026nbsp;to\u0026nbsp;all\u0026nbsp;instructors\u0026nbsp;and educators of the faculty of medicine of Sousse who participated in this research and contributed their time.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003eThe ETHIC medical\u0026nbsp;committee\u0026nbsp;of the faculty of the Medicine of Sousse (Comit\u0026eacute;d\u0026rsquo;\u0026eacute;thiquem\u0026eacute;dicale \u0026agrave; la facult\u0026eacute; de medecine de Sousse) in her headPrSouheil Mlayeh approved this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003enot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e Data sets used and/or analyzed in this study are available from the corresponding author upon reasonable request. All material is the property of the authors, and/or no permission is required. Data are provided in related files\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;Competing interests:\u003c/strong\u003e The authors declare no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: No funding\u003cstrong\u003e\u003cdel cite=\"mailto:Curie\" datetime=\"2024-03-12T09:59\"\u003e\u0026nbsp;\u003c/del\u003e/\u003c/strong\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eS.L and W.N wrote the main manuscript\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eH.B\u003cins cite=\"mailto:Curie\" datetime=\"2024-03-12T09:59\"\u003e.\u003c/ins\u003e and O.M prepared the tables and figures\u003c/p\u003e\n\u003cp\u003eD.L and Naou.Ch reviewed the manuscript\u003c/p\u003e\n\u003cp\u003eR.M and Nab.Chreviewed the final methodology and tables.\u003c/p\u003e\n\u003cp\u003eS.L is the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMasson E. 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Nursery Assistants\u0026rsquo; Performance and Knowledge on Cardiopulmonary Resuscitation: Impact of Simulation-Based Training. Front Pediatr. 2020;8:356.\u003c/li\u003e\n\u003cli\u003eSimulation en sant\u0026eacute; : 1 re exp\u0026eacute;rience en D.E.S de m\u0026eacute;decine interne | Request PDF [Internet]. [cit\u0026eacute; 4 mai 2024]. Disponible sur: https://www.researchgate.net/publication/321437322_Simulation_en_sante_1_re_experience_en_DES_de_medecine_interne\u003c/li\u003e\n\u003cli\u003eSilva NL de C, de Melo M do CB, Liu PMF, Campos JPR, Arruda M de A. Teaching basic life support for medical students: Assessment of learning and knowledge retention. J Educ Health Promot. 2023;12:218.\u003c/li\u003e\n\u003cli\u003eApport de la simulation pour la prise en charge des urgences vitales - Google Search [Internet]. [cit\u0026eacute; 4 mai 2024]. 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Early acquisition of non-technical skills using a blended approach to simulation-based medical education. Adv Simul. 14 ao\u0026ucirc;t 2017;2(1):12.\u003c/li\u003e\n\u003cli\u003eMagill JC, Tolley N. Non-technical Skills Simulation Training. Curr Otorhinolaryngol Rep. 1 mars 2020;8(1):106‑10.\u003c/li\u003e\n\u003cli\u003eHawkins A, Tredgett K. Use of high-fidelity simulation to improve communication skills regarding death and dying: a qualitative study. BMJ Support Palliat Care. d\u0026eacute;c 2016;6(4):474‑8.\u003c/li\u003e\n\u003cli\u003eLee JY, Mucksavage P, Canales C, McDougall EM, Lin S. High Fidelity Simulation Based Team Training in Urology: A Preliminary Interdisciplinary Study of Technical and Nontechnical Skills in Laparoscopic Complications Management. J Urol. avr 2012;187(4):1385‑91.\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, Medical students, Education, Undergraduate, cardiopulmonary resuscitation","lastPublishedDoi":"10.21203/rs.3.rs-4411571/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4411571/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eHealthcare simulation has become a crucial pedagogical technique across various medical disciplines.This approach use, virtual reality, or standardized patients to replicate clinical scenarios, has proven vital in preparing medical students for high-risk situations, ensuring the safety and effectiveness of critical patient management through the acquisition of technical skills, teamwork, and the ability to handle exceptional scenarios. Aims of this study wereto evaluate the theoretical knowledge of students before and after the simulation-based training (SBT) of the \"Advancedcardiopulmonary resuscitation(CPR)\" module, to assess their technical and non-technical skills and to describe their satisfaction.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis study, conducted at the Faculty of Medicine in Sousse, Tunisia, sought to objectively evaluate the impact of SBT on the theoretical knowledge, technical skills, and non-technical competencies of graduate Medical Students, during their advanced (CPR) training. The researchers employed a pre-experimental design, assessing students before and after the simulation-based workshops covering various CPR-related topics.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eWe have demonstrated that the SBT was highly valued by the learners and led to significant improvements in their theoretical knowledge,There is a positive correlation between the pre and post-test score, with a correlation coefficient of r\u0026thinsp;=\u0026thinsp;0.474, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001, r\u0026sup2; = 0.245. For technical skills, (69.8%) have improving their external cardiac massage (ECM) technique by the exam day, while 14 (16.3%) exhibited a decline (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).Additionally, \"non-technical skills\"( NTS) were assessed using the Anesthesia Non-Technical Skills(ANTS) scoreamong these students, 85 (89.5%) improved their scores, while 10 (10.5%) maintained their initial score (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).At the end of the training sessions, a strong statistically significant correlation was found between the sum of post-test scores, ANTS score, cardiac massage score, and the final score of the simulated practical \u0026ldquo;ECOS\u0026rdquo; exam (r\u0026thinsp;=\u0026thinsp;0.762, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, r\u0026sup2;=0.581).Student satisfaction was evaluated; overall, students' impressions were predominantly excellent in over 50% of responses.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe study's contribution to the growing body of evidence supporting the integration of simulation-based learning in the formative years of medical education is particularly noteworthy. Simulation can accelerate skill acquisition and enhance the transition of knowledge and self-confidence when faced with real-life critical scenarios.\u003c/p\u003e","manuscriptTitle":"Contribution of Simulation-Based Learning in Advanced Cardiopulmonary Resuscitation for Undergraduate Medical Students","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-05 17:18:09","doi":"10.21203/rs.3.rs-4411571/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":"15c6b620-3f8d-40d8-a93a-e608f13cdc91","owner":[],"postedDate":"June 5th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-11-12T09:53:16+00:00","versionOfRecord":[],"versionCreatedAt":"2024-06-05 17:18:09","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4411571","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4411571","identity":"rs-4411571","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}