Effect of simulation-based human factors training among emergency medicine healthcare providers on paediatric airway management: a study protocol for a quasi-experimental pre-post study at a tertiary healthcare centre in Karachi, Pakistan

Abstract

Introduction

Up to 40% of major complications during airway management result from human factors. Through human factors such as planning, effective communication, strong leadership and clear role allocation within the team, smooth airway securement can be facilitated and the risk of complications reduced. Simulation-based teaching provides real-time situations and allows healthcare workers and learners to identify, refine and improve their technical and non-technical skills. This study aims to evaluate the effect of simulation-based human factors training on airway management among healthcare providers working in the emergency department of a tertiary healthcare setting in a low- and middle-income country.

Methods and analysis

This will be a quasi-experimental study with a pre-post design to infer the impact of simulation-based human factors training among emergency medicine healthcare providers on paediatric airway management. The study will be conducted at the Centre of Innovation in Medical Education, Aga Khan University Hospital, Karachi. Participants will include emergency department healthcare providers who meet the inclusion criteria and are selected through purposive non-probability sampling. A total of 74 participants will be enrolled. Data will be analysed using Stata. Descriptive statistics will be presented as frequencies and percentages for categorical variables and as means with SD or medians with IQRs for continuous variables as appropriate. Changes in first-pass intubation success and time to secure the airway (≤30 vs >30 s) following the intervention will be assessed using McNemar’s test. Changes in TEAM, CTS and NASA-TLX scores will be evaluated using a paired t-test. Generalised Estimating Equations will be used to identify factors associated with airway management outcomes, with results reported as adjusted ORs and 95% CIs. A p-value <0.05 will be considered statistically significant.

Ethics and dissemination

Ethical approval has been obtained from the Aga Khan University Ethical Review Committee (ERC: 2026–12851-41186). Written informed consent will be obtained from all participants, and participation will be voluntary. Findings will be disseminated through thesis submission, conference presentations and peer-reviewed publications.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• This study uses a structured, simulation-based interventional design, enabling standardised assessment of human factors under controlled, reproducible conditions.

• The use of predefined performance metrics, such as first-pass success rate and time to secure airway, ensures objective measurement of outcomes.

• The methodology enables direct observation and assessment of team dynamics and human factors, which are otherwise difficult to quantify in real-world clinical settings.

• A key limitation is that the study assesses performance in a simulated environment, which may not fully replicate the clinical complexity and stress of real-world practice.

• Another limitation is its single-centre design and limited sample size, which may affect the external validity and generalisability of the results.

Introduction

Paediatric airway management is a cornerstone of care in departments providing paediatric services, particularly emergency medicine, intensive care units and anaesthesia.¹ The paediatric airway differs significantly from that of adults due to distinct anatomical and physiological characteristics. These include a smaller mandible, a relatively larger tongue, a higher and more anterior larynx, a large and floppy epiglottis, a larger head with a prominent occiput, reduced functional residual capacity, a higher metabolic rate and a shorter safe apnoea time.^1–3 These differences increase children’s vulnerability to airway-related complications.^1–3 Any delay or interruption in securing the airway may result in adverse events ranging from hypoxaemia to cardiac arrest, potentially leading to death or long-term neurological impairment.^4–8

The most common reported complications during paediatric airway management include desaturation (pulse oximeter <90%), affecting around 24% of the patients, followed by mainstem intubations (9.1%), hypotension (2.6%) and cardiac arrest and arrhythmias (1.4% and 1.2%, respectively).⁴ The likelihood of complications increases with repeated intubation attempts.⁷ Regional data indicate that 19% of paediatric patients intubated in emergency departments (EDs) experienced complications, with 10% requiring cardiopulmonary resuscitation and 5% needing multiple intubation attempts.⁵

The human factor (ergonomics) definition, as adopted by the International Ergonomics Association in 2000, is ‘the scientific discipline concerned with the understanding of interactions among humans and other elements of a system, and the profession that applies theory, principles, data and methods to design to optimise human well-being and overall system performance’.^{9 10} In healthcare, human factors encompass cognitive, social and decision-making skills, as well as interactions with the environment and organisational structures.^11–13 Effective planning, communication, leadership and clear role allocation within teams are essential for safe airway management. Notably, up to 40% of major airway complications are attributable to human factors.^{12 14}

Simulation-based teaching (SBT) has emerged as a key educational strategy for improving both technical and non-technical skills. It offers realistic clinical scenarios in a safe learning environment, enabling healthcare providers to refine procedural skills, communication, leadership and decision-making.^15–17 Advances in SBT include high-fidelity mannequins, virtual reality and hybrid simulation models. Evidence suggests that SBT enhances confidence, reduces anxiety, improves clinical performance and promotes long-term skill retention compared with traditional teaching methods.^16–19

Human factor skills are not innate and can be developed through structured training. SBT has demonstrated improvements in team performance, guideline adherence, airway management and resuscitation outcomes.^{19 20} Systematic reviews have shown sustained improvements in team performance and reduced cognitive load following repeated simulations.^{19 21} While simulation-based airway training has been extensively studied in high-income countries, there is sparse evidence from low- and middle-income countries (LMICs). This scarcity is particularly evident regarding structured human factors education for multidisciplinary paediatric emergency teams. Most research primarily concentrates on technical airway skills or involves only physicians. Consequently, little is understood about how simulation-based human factors training influences leadership, communication, situational awareness, team coordination and cognitive workload in resource-constrained emergency environments. This study aims to address this gap by evaluating a structured human factors curriculum tailored for paediatric emergency care providers in Pakistan.

Research question

Do simulation-based human factors training among healthcare providers improve performance metrics and human factors outcomes of paediatric airway management in the ED of a tertiary care hospital in Karachi, Pakistan?

Objectives

Primary objectives

To assess the effect of simulation-based human factors training on the performance metrics and human factors outcomes of paediatric airway management among healthcare providers.

Secondary objectives

1. To determine the association between self-reported cognitive load of providers and performance during paediatric airway management.

2. To compare team performance metrics between high-acuity and low-acuity teams during simulated paediatric airway scenarios (by increasing the complexity of the scenario).

Hypothesis

Null hypothesis

1. Simulation-based human factors training among healthcare providers working in the ED will cause less than or equal to 15% increase in the first-pass success rate from the baseline.

2. Simulation-based human factors training among healthcare providers working in the ED will not affect the time-to-airway securement, and it will remain more than or equal to 30 s.

Alternative hypothesis

1. Simulation-based human factors training among healthcare providers working in the ED will increase the first-pass success rate by more than 15%.^22–24

2. Simulation-based human factors training among healthcare providers working in the ED will decrease time-to-airway securement below 30 s.^{25 26}

Conceptual framework

The conceptual framework (figure 1) illustrates how simulation-based human factors training enhances airway management performance. By providing a realistic and psychologically safe environment, simulation allows participants to make mistakes without consequences and learn through corrective practice. Repetitive exposures to high-risk scenarios, combined with structured debriefing and targeted feedback, support deeper learning, confidence-building and skill acquisition. These mechanisms collectively reduce cognitive load and strengthen both technical and non-technical skills, ultimately improving key performance metrics, including higher first-pass success rates and reduced time to secure the airway.

Figure 1. Conceptual framework illustrating the impact of human factors training on paediatric airway management performance.

Methodology

Operation definitions

First-pass success will be defined as successful passage of the endotracheal tube into the trachea on the first attempt.

Time-to-secure airway will be defined as the interval from insertion of the laryngoscope blade into the oral cavity to confirmation of successful tracheal intubation by sustained end-tidal carbon dioxide (ETCO_₂) tracing and visible bilateral chest expansion in the simulated environment.

Difficult airway will be defined as an airway where an experienced healthcare provider encounters or anticipates difficulty with bag-mask ventilation, direct or indirect laryngoscopy (ie, visualisation of the glottis/vocal cords), tracheal intubation, placement of supraglottic devices or performing a cricothyrotomy.

Study design

This study will employ a quasi-experimental pre-post design to evaluate the effect of simulation-based human factors training on paediatric airway management among emergency medicine healthcare providers. The intervention aims to improve both technical and non-technical skills, including airway management, communication, leadership, teamwork, situational awareness and decision-making during paediatric airway emergencies.

Conducting randomised experiments during real paediatric airway emergencies is neither practical nor ethically feasible because patient care decisions must be made immediately, and withholding potentially beneficial training may compromise patient safety. Therefore, simulation provides a realistic, standardised and risk-free environment in which multidisciplinary teams can practise and refine critical skills without exposing patients to harm. This approach allows the assessment of human factors and performance outcomes under controlled conditions while maintaining clinical relevance.

Study setting

The study will be conducted at the Centre of Innovation in Medical Education (CIME) on the healthcare staff working in the ED at the Aga Khan University Hospital (AKUH), Karachi.

AKUH is one of the largest private hospitals in the country. It has an 82-bed Department of Emergency Medicine, of which 22 beds are designated for the Paediatric Emergency Medicine (PEM) section. AKUH is located in Karachi, a metropolitan city, and serves as the referral centre not only for Sindh province but also for the whole country. PEM receives around 20 000 to 25 000 paediatric patients every year. With facilities for some of the rare subspecialities that are not easily accessible elsewhere in the country, this hospital serves as the major referral hub for very rare and critical cases as well.

CIME at AKUH is a state-of-the-art facility which is equipped with cutting-edge technology and high-quality mannequins, along with internationally qualified faculty and staff. CIME runs over 200 courses and has a capacity for over 900 students. It has proven to be a fundamental driver of transformation in healthcare education through simulation-based learning.

Study participants

Study participants will be emergency residents, paediatric emergency physicians (including faculty, senior medical officers and staff medical officers) and nursing staff. Teams will undergo simulations, followed by debriefing, resimulation and feedback sessions. Each team will comprise participants from all groups, including residents, paediatric emergency physicians (either senior medical officers or staff medical officers) and nursing staff.

Eligibility criteria

Inclusion criteria

• Healthcare staff directly related to paediatric airway management (comprising physicians and registered nurses) working in the Department of Emergency Medicine at AKUH.

• Physicians and registered nurses who are working in the paediatric emergency section and have at least 6 months of experience working in the ED.

• Those giving consent to participate in the study.

Exclusion criteria

• Physicians or registered nurses temporarily rotating to the paediatric ED (such as paediatric or other subspecialty residents) who may have 6 months of overall emergency experience but are not permanently posted in the Department of Emergency Medicine.

• Individuals who have previously attended simulation-based training with similar objectives or outcome measures as the present study.

• Physicians or nurses who are officially retired (or above 60 years of age) but currently working in the Department of Emergency Medicine on a daily-wage or locum basis are excluded from the study to maintain homogeneity within the teams.

Sampling technique

A purposive non-probability sampling technique will be used to select the staff working in the Department of Emergency Medicine.

Sample size

A total sample size of 74 participants is required for this study. The sample size is calculated in Stata V. 17 using the McNemar test for paired proportions, in a study by Mahli et al,²⁷ the success-to-failure transition rate was reported as negligible (approximately 0%), while the failure-to-success transition rate was 8%. For the present study, a more conservative approach is adopted to ensure adequate power. We assumed a 5% success-to-failure transition rate and a 20% failure-to-success transition rate, corresponding to an expected overall improvement of 15% (Δ=0.15). Using these assumptions, with a 5% significance level (α=0.05) and 80% power, the required sample size is estimated to be 67 participants. This is a single-contact study, so loss to follow-up is less likely, so we are allowing for 10% attrition. So, the final sample size turned out to be 74 healthcare providers meeting the inclusion criteria.

Recruitment of study participants

Study participants will be recruited from the ED of AKUH. Healthcare providers directly involved in patient care who meet the inclusion criteria will be eligible. Permission will be sought from the chair, section heads and the head nurse of the Department of Emergency Medicine to enrol participants in the study. To ensure uninterrupted clinical operations, participants will be allocated into two groups based on their availability and duty schedules. Participation will not occur during duty hours (ie, paid duty hours) but during participants’ personal time. This study is designed as an educational learning activity, and participation will be completely voluntary. Participation in the study is expected to improve participants’ technical and non-technical skills. However, participants will not receive monetary compensation.

Simulation-based training sessions will be scheduled on two separate days between 17 and 31 August 2026, depending on space availability at CIME, AKUH. Available participants on the day of the simulation will be randomly divided into four groups. Group allocation will be determined by computer or by drawing names from a box. Groups will be colour-coded as red, green, blue and black. Physicians (including faculty, postgraduate residents and senior/staff medical officers) and registered nurses will be drawn separately. The first member selected will be assigned to the red group, the second to the green group, the third to the blue group and the fourth to the black group. If more than one staff/senior medical officer, postgraduate resident or registered nurse needs to be allocated to groups, the sequence will be repeated for the second round. This procedure will be carried out for both shifts (morning and evening) on both days of the SBT.

Participants will be divided into small groups for the baseline assessment (pre-test), and first-pass success rate and time-to-intubation will be recorded. The complexity of the cases will gradually increase to assess non-technical skills, such as cognitive load and team-based communication, alongside technical skills. This will be followed by a debrief session and explanation/training (simulation-based) of the identified technical and non-technical skills. After SBT, a different scenario with a similar pattern of increasing complexity will be run, and an assessment (post-test) will be conducted. Figure 2 illustrates the participant recruitment and enrolment process.

Figure 2. Participant recruitment and enrolment process.

Study variables

Outcome variable

Alongside airway performance metrics, the study will also evaluate non-technical human factors skills using validated assessment tools. These will measure teamwork, communication, leadership, situational awareness, task management, decision-making and cognitive workload in paediatric airway management scenarios.

First-pass intubation success rate

First-pass intubation will be measured in terms of success versus failure ratio. If intubation is successful with the first attempt, it will be counted as the successful first-pass intubation. Total attempts at successful intubation will also be measured. Presimulation- and postsimulation-based success rates will be checked and analysed to determine the proportion improvement in the post-SBT.

Time-to-secure airway time

Time taken from insertion of the laryngoscope blade into the oral cavity to confirmation of successful tracheal intubation by sustained ETCO_₂ tracing and visible bilateral chest expansion in the simulated environment will be noted in terms of the seconds taken to achieve successful intubation. If more than one attempt is taken for intubation, then the time for each attempt will be documented, and it will also be noted whether the intubation was successful or not.

Exposure variable

Simulation-based training

Simulation-based training will be considered as the exposure. This will be conducted at the CIM at AKUH, Karachi. Participants will be divided into small groups of four or six individuals. The groups will be formed to fully represent an actual emergency care team, including a senior doctor/faculty member, one or two staff or senior medical officers, emergency medicine residents and 1–2 registered nurses.

SBT will be conducted on two different days, with two shifts per day. Shifts will be divided into morning and afternoon shifts. Each shift will include 3–4 groups, and each group will be coloured red, blue, green and black to avoid the mixing of the group activity performance results.

A 15-minute orientation session will be conducted in a classroom setting, where participants will be guided on how to proceed and what is expected of them. This orientation session will be conducted by either the principal or co-principal investigator, both of whom are experts in emergency airway management. After the orientation, participants will move to the simulation lab, where a case scenario will be run. The complexity of the case will be increased progressively to assess the different aspects of the team, including leadership, teamwork, task achievement, communication, situational awareness, decision-making, role responsibility and effect on the outcome variable. This will be followed by a structured debrief session, where all shortcomings will be discussed in detail. This debriefing session will be followed by a post-debrief case scenario to assess the effect of SBT on first-pass success and time from decision to airway securement.

To minimise potential testing and familiarity effects associated with a pre-post study design, the postintervention assessment will employ a different but educationally equivalent paediatric airway scenario rather than an identical case. Both scenarios will be developed using the same learning objectives and standardised simulation design principles, ensuring comparable clinical complexity, airway difficulty and expected technical and non-technical performance. Although the clinical presentations will differ, participants will be required to demonstrate the same competencies, including airway management skills, communication, leadership, teamwork, situational awareness, decision-making and crisis resource management. Participants will not be informed in advance of the details of the postintervention scenario.

Patient and public involvement

Patients and members of the public were not involved in the design, conduct, reporting or dissemination plans of this research.

Data collection tools

A detailed, structured questionnaire is designed for this study (online supplemental appendix 1). As this is a pre-post study, the questionnaire will be filled twice—once before and once after the intervention. The first part of the questionnaire contains sociodemographic information, including age, gender, designation, qualification, years of experience, previous experience such as basic life support and pediatric advanced life support (BLS/PALS) certification, previous airway management experience, any prior training received and other related experiences. This section will remain the same and will be completed before the pre-debrief session of the SBT begins.

The sociodemographic section will be followed by the pretesting section. This part will be filled twice—once for the pre-debrief simulation case scenario run and another time for the post-debrief SBT. This section includes the evaluation of the team for adherence to rapid sequence intubation (RSI) steps, any complications (such as vital sign changes) observed and two validated scales, the Team Emergency Assessment Measure (TEAM) and the Clinical Teamwork Scale (CTS), to assess leadership, teamwork, task management, team communication, situational awareness, decision-making and role responsibility. These validated tools will enhance airway performance metrics by offering a structured evaluation of non-technical human factors skills during simulation scenarios. This entire section will be filled by the investigator/facilitator while observing team dynamics during the simulation-based case scenarios, in which the complexity/acuity of the situation will gradually increase. The third section of the questionnaire will be the self-administered NASA Task Load Index (NASA-TLX) score, which the participants will complete independently and anonymously.

Simulation sessions will be video recorded. Independent assessors who are not involved in participant instruction will score performance using standardised assessment tools wherever feasible. Each participant will be assigned an identification (ID) number at the start of the simulation, and this ID will be used for both preassessment and postassessment. Participant names or any personal identifiers will not be recorded on the questionnaire, and confidentiality will be maintained throughout all stages of data collection.

Data analysis plan

Data will be collected on paper-based questionnaires and then entered into an Excel sheet. The data will be cleaned in Excel and subsequently transferred to STATA statistical software for analysis.

Descriptive statistics

Frequencies and percentages will be reported for categorical variables such as gender, position held within the ED, qualifications and years of experience (categorised as <2 years, 2 years to <5 years, 5 years to <10 years and >10 years). The same will be reported for previous experiences, including PALS/BLS certification, previous airway management training, prior attempts at intubation, prior involvement in cardiopulmonary resuscitation and first-pass success. Mean±SD or median with IQR will be reported for continuous variables such as age, time-to-secure airway and TEAM, CTS and NASA-TLX scores.

Analytic strategy

As this is a pre-post study design on the same individuals, paired statistical methods will be used. The primary outcomes, first-pass success rate and the time-to-secure airway, will be analysed using McNemar’s test. Discordant pairs will be reported, and a p-value of <0.05 will be considered significant. The absolute pre-post difference with a 95% CI will also be calculated using the paired proportion difference method. For secondary outcomes, paired t-tests will be used for TEAM, CTS and NASA-TLX scores. Preintervention and postintervention mean scores, mean differences with 95% CIs, and p-values will be reported. Internal consistency (Cronbach’s α) of self-administered scales will also be reported.

Subgroup analysis

Subgroup analysis will be conducted based on designation within the ED, qualifications, years of experience and previous intubation experience.

Univariate analysis

Each independent variable will be regressed separately against the binary outcome (first-pass success and the time-to-secure airway) using simple Generalised Estimating Equations (GEE). For both primary outcomes, a GEE with a logit link function and exchangeable correlation structure will be used to obtain unadjusted ORs with 95% CIs. The predictor variables with a p-value <0.20 in the univariate GEE screening will be considered eligible for inclusion in the multivariable model.

Multicollinearity

Multicollinearity among predictor variables will be assessed prior to fitting the multivariable GEE model. It will be assessed between qualitative predictor variables using Cramér’s V and between quantitative and qualitative predictor variables using the Eta (η) coefficient. A cut-off of >0.80 will be considered as a substantial correlation. If any two variables are found to be highly correlated, the variable with the more plausible clinical association will be retained.

Multivariable analysis

A stepwise manual model-building approach will be used. The variable with the highest chi-square value in univariate screening will be entered first into the multivariable model. For both primary outcomes (that are binary outcomes), GEE with a logit link function and exchangeable correlation structure will be used. Adjusted ORs with 95% CIs will be reported. Variables with a p-value <0.10 will be retained in the final model.

Validity of the study

Internal validity

This study has some threats to internal validity which will be addressed in the design phase of the study.

Selection bias

Physicians and staff frequently involved in ED resuscitation and intubation may have better knowledge of paediatric airway management and perform better than less experienced staff, creating potential selection bias if teams include more senior members. However, this bias is likely minimal due to balanced shift staffing and will be further reduced by randomly selecting team members from those present during the SBT.

Hawthorne effect

The Hawthorne effect may lead participants to change their behaviour because they know they are being observed, potentially distorting real-life performance. To reduce this, direct observation will be avoided by monitoring participants remotely from a separate room using a one-way mirror and communication tools. Observers can control simulation settings without being physically present. Participants will be reassured about confidentiality, and no individual performance will be singled out; debriefing will focus on the group. Additionally, as the simulation becomes more demanding, participants are more likely to revert to their natural behaviour, further minimising this effect.

Observer bias (investigator expectancy bias)

Observer bias may arise when investigators unintentionally influence participants’ performance through hints or guidance, potentially improving post-test results. This will be minimised by using structured skill checklists, training observers to record performance objectively, avoiding real-time coaching or corrective feedback during the simulations and applying validated scales to assess team-based skills.

Interviewer bias

Interviewer bias can occur when the interviewer unintentionally influences participants’ responses during data collection/interview. However, the risk of interviewer bias is minimal in this study, as it does not involve any open-ended questions or subjective probing. Instead, validated and structured tools (the TEAM and CTS scales) are used for objective assessment by investigators, whereas the NASA-TLX is self-reported by participants. This standardised and objective approach minimises the potential for investigator influence on responses.

External validity

The study’s findings are generalisable to healthcare providers working in high-acuity paediatric EDs in LMICs, where care is delivered by multidisciplinary teams. However, they may not directly apply to low-acuity settings such as rural or secondary care facilities, though the insights could still be useful indirectly. By involving all key clinical roles and reflecting real-world practices, the study provides valuable evidence, especially given the limited existing literature, and may guide future simulation-based training programmes and multicentre research.

Ethics and dissemination

Ethical considerations

The study will be conducted in accordance with the Declaration of Helsinki. The study will seek approval from the chief medical officer and the chair of the department of emergency medicine before commencement. Ethical approval has already been obtained from the ethical review committee (ERC) of the Aga Khan University Hospital and has been assigned the reference number ERC-2026-12851-41186.

Informed consent will be obtained from all participants enrolled in the study. Since all participants are qualified personnel, consent will be taken in English. Participants will receive clear instructions about the study, including its implications and importance. They will also be informed about the expected duration of the training sessions. Attendees will be made aware that the training may enhance both their technical and non-technical skills. Participants will have full autonomy to withdraw from the study at any time without any penalty. It will be ensured that participation is entirely voluntary and not influenced by any enforced appearance from the head nurse or other administrative personnel.

Confidentiality will be strictly maintained. No personal identifiers such as names or employee numbers will be recorded. Each participant will be assigned a unique study ID, which will be documented in the study proforma and securely stored. Data will be collected using Research Electronic Data Capture, which will be password protected. The password will be accessible only to the research team and the principal investigator. Consent forms will be collected in hard copy and securely stored by the principal investigator.

During debriefing sessions, efforts will be made to avoid highlighting any individual in group discussions. If a specific issue is identified during pre-debriefing, individual feedback will be provided privately. Group feedback will be shared during the debrief, while individual feedback will be given in isolation. Efforts will be made to briefly meet with each participant one-on-one so that no individual feels singled out or targeted. If any unsafe practice is observed during the SBT, it will be communicated privately to the individual participant. However, if any practice is identified as grossly unsafe and is observed among a majority of participants, recommendations will be communicated to the departmental chair for organising targeted training (eg, workshops or educational activities) to address the issue at a broader level. In addition, individual feedback will be provided privately to each participant to ensure corrective learning. Performance information of individual participants or groups will not be shared with others. Participants will be provided with refreshments during the study activities.

Dissemination strategy

As this study forms part of a master’s thesis programme, the results will be submitted to the university, and the completed thesis will be made publicly available following its successful defence. The findings will also be disseminated through publication in peer-reviewed international journals and presentation at relevant scientific conferences to reach the broader healthcare community.

Public health implications

This study focuses on improving both technical and non-technical skills of healthcare providers working in paediatric EDs, specifically in managing paediatric airways. Airway management is often needed in critically ill patients, and expertise at this stage can save lives. The simulation-based human factor training will enhance human factor skills, reduce complications during airway management and ultimately decrease mortality and morbidity. It aims to improve neurologically favourable survival outcomes by strengthening teamwork, communication and decision-making under pressure.

Additionally, this study will guide the development of paediatric airway management courses that incorporate simulation-based training for human factors. For LMICs like Pakistan, where emergency medicine is still developing, this approach can open new avenues for training. It will help identify weaknesses in managing high-stress situations, which often cause psychological distress and impair cognitive performance among healthcare providers.

By improving communication and leadership qualities, this training can reduce medical errors and serve as an effective patient safety and quality improvement tool. It will prepare healthcare providers to handle high stress, cognitively demanding scenarios in emergency settings. Furthermore, the findings can inform curriculum design for EDs and extend to paediatric critical care units, including paediatric and neonatal intensive care.