Accepted for/Published in: JMIR Medical Education
Date Submitted: Sep 19, 2025
Date Accepted: Jan 15, 2026
Warning: This is an author submission that is not peer-reviewed or edited. Preprints - unless they show as "accepted" - should not be relied on to guide clinical practice or health-related behavior and should not be reported in news media as established information.
Remote Augmented Reality Versus Traditional Simulation for Assessing Team Leader Performance in a Cardiac Arrest Scenario: a noninferiority randomized controlled trial
ABSTRACT
Background:
Simulation-based education is crucial for training health care professionals in advanced cardiac life support (ACLS). 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 non-inferior to traditional in-person simulation for assessing team leader performance during a ventricular fibrillation (VF) cardiac arrest scenario.
Methods:
This international, non-inferiority randomized trial was conducted in two centers. 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 VF cardiac arrest case as team leader. Leader performance was assessed using an adapted, validated checklist-based instrument for cognitive leadership and an observational behavioral measure (Behaviorally Anchored Rating Scale, BARS). Secondary outcomes included AR participants’ evaluations of usability and ergonomics.
Results:
Forty two participants fully completed the study procedures (AR: n = 22, in-person: n = 20). The AR group demonstrated non-inferior performance compared to the traditional group across all outcomes. Checklist scores were 41.6 (SD=6.2) and 42.6 (SD=5.8) in the AR and traditional groups, respectively. The AR group’s 95% confidence interval [38.9–44.4] was above the 20% non-inferiority threshold of 34.1. Usability and ergonomics were favorably reported by most participants.
Conclusions:
Participants in the remote AR simulation demonstrated non-inferior 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. Clinical Trial: clinicaltrials.gov number: NCT06326450
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