From leadership research to district action: Remote Augmented Reality Versus Traditional Simulation for Team Leader Assessment in a Cardiac Arrest Scenario: Noninferiority Randomized Controlled Trial

AI-assisted editorial implementation guide. Proposed district actions are separate from the original authors’ findings and recommendations. Independent peer review of this guide is not asserted.

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Evidence and transfer

Education-related source: verify which participants, institutions and outcomes were actually studied before district adoption. Source publication type: research-article. License and identity checks do not establish study quality or causality.

Original authors’ abstract, reproduced under the source license:

Abstract Background Simulation-based education is crucial for training health care professionals in advanced cardiac life support. However, access to high-fidelity in-person simulation is frequently limited by geographic, logistical, and financial constraints. Augmented reality (AR) offers the potential to deliver remote, immersive training experiences that may overcome these barriers, but its effectiveness compared with traditional simulation remains uncertain. Objective This study aimed to determine whether remote AR simulation is noninferior to traditional in-person simulation for assessing team leader performance during a ventricular fibrillation cardiac arrest scenario. Methods This noninferiority randomized trial enrolled participants at the State University of Campinas (UNICAMP), Brazil, and used cross-continental remote instruction from Stanford University (in the United States) for the AR arm. A total of 50 health care professionals were randomized to either remote AR simulation with a geographically distant instructor (n=25) or traditional in-person simulation (n=25). All participants completed an identical ventricular fibrillation cardiac arrest case as team leaders. Leader performance was assessed using an adapted, validated checklist-based instrument for cognitive leadership and an observational behavioral measure (Behaviorally Anchored Rating Scale). Secondary outcomes included AR participants’ evaluations of usability and ergonomics. Results A total of 42 participants fully completed the study procedures (remote AR group: n=22; traditional in-person group: n=20). The AR group demonstrated noninferior performance compared to the traditional group across all outcomes. The mean checklist scores were 41.6 (SD 6.2) and 42.6 (SD 5.8) in the remote AR group and traditional in-person group, respectively. The AR group’s 95% CI (38.9‐44.4) was above the 20% noninferiority threshold of 34.1. Usability and ergonomics were favorably reported by most participants. Conclusions Participants in the remote AR simulation demonstrated noninferior team leader decision-making and behavioral performance compared with those in traditional in-person simulation. These findings suggest that remote AR may be a viable strategy to expand access to scenario-based assessment of cardiac arrest leadership, particularly in resource-limited settings. AR participants also reported high usability and low ergonomic burden, indicating comfortable headset use.

Study methods

This international trial used a parallel, noninferiority design with a 1:1 allocation ratio to compare team leader performance in a simulated VF cardiac arrest scenario. All participants were recruited and completed study procedures at the State University of Campinas (UNICAMP), Brazil. Stanford University functioned as the remote instructor site for the AR arm. Participants were randomized to complete either a remote instructor–led AR simulation or a traditional in-person simulation. Recruitment occurred between June 20, 2024, and August 2, 2024, across 2 academic centers. The study was prospectively registered at ClinicalTrials.gov (NCT06326450; March 15, 2024).

Limitations

This study had several limitations. First, recruitment at a single institution limits external validity, and replication at other sites is needed. Second, enrolling only residents restricts generalizability to other learner groups, especially medical students. Third, usability and ergonomic data were self-reported, which may introduce response bias despite the use of validated scales. Fourth, the study evaluated performance at a single time point and therefore does not provide information on longitudinal consistency or reproducibility of assessment outcomes. Fifth, 2 participants were excluded after randomization due to incompatibility between corrective glasses and the AR headset. This exclusion applied only to the AR group and reflects a technical device limitation rather than participant characteristics. Sixth, cardiopulmonary resuscitation technical quality metrics (eg, compression depth, rate, and recoil) were not measured; therefore, our findings speak to team leader cognition and nontechnical behaviors (decision-making, communication, and coordination) rather than hands-on resuscitation technical performance. Seventh, the study used a single VF scenario, which may not capture the full range of skills needed for real-world cardiac arrest. Finally, because assessments were conducted live and the simulation modality was visually apparent, raters were not blinded to group allocation, which may have introduced observer bias in favor of or against the AR modality.

A 90-day district inquiry

Days 1–15 · Appraise. Read the source methods, recruitment, comparator, outcomes and limitations. Record how the study setting differs from your district and which claim the design can support.
Days 16–30 · Design. Pilot a structured team debrief in one voluntary staff team. Invite dissent, record a specific improvement action and assign responsibility without collecting identifiable criticism. Agree participation, privacy protections, baseline and stopping rules before starting.
Days 31–60 · Observe. Collect the pre-agreed measures, keep a log of implementation changes and invite confidential voluntary feedback. Preserve existing support for staff and learners.
Days 61–90 · Decide. Compare participation distribution, action completion, near-miss reporting and a consistent voluntary team-climate measure. Increased reporting may reflect greater openness rather than more errors. Make a dated decision to stop, revise or extend the inquiry.

Board decision brief

Present the local problem, source setting, evidence limits, intervention, responsible owner, total cost, measured changes and uncertainty. Separate staff perceptions, implementation measures and student learning outcomes.

Attribution and reuse

Renan Gianotto-Oliveira; Marcos Rojas; Maria Queiroz; Flávia Zanchetta; Anabel Ferrari; Lucas Kojima; Alexandre Paula; Bruno Campos; Dario Cecilio-Fernandes; Thomas J Caruso. Remote Augmented Reality Versus Traditional Simulation for Team Leader Assessment in a Cardiac Arrest Scenario: Noninferiority Randomized Controlled Trial. JMIR Medical Education (2026-03-16). https://doi.org/10.2196/84367

Prepared 2026-11-07. Source authorship and DOI are preserved. The abstract and source passages are attributed extracts; this editorial guide is offered under the same CC BY 4.0 license.