Effectiveness of Integrating High-fidelity Simulation and Team-Based Learning in Pediatric postgraduates CPR Training: A Mixed Method Running Head：High-fidelity Simulation and TBL

doi:10.21203/rs.3.rs-4690890/v1

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Research Article

Effectiveness of Integrating High-fidelity Simulation and Team-Based Learning in Pediatric postgraduates CPR Training: A Mixed Method Running Head：High-fidelity Simulation and TBL

https://doi.org/10.21203/rs.3.rs-4690890/v1

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Background Given the overall lack of cardiopulmonary resuscitation (CPR) training in society, Standardized CPR training is very imperative to bolster widespread CPR adoption. At present, the traditional teaching method is not conducive to improving students' comprehensive ability, however, there is limited literature on the combined use of high-fidelity simulation and

team-based learning (TBL) in pediatric graduate student education. The study aimed to evaluate the effectiveness of using high-fidelity simulation combined with TBL teaching method in standardized training of cardiopulmonary resuscitation for pediatric postgraduates.

Methods

This mixed-methods study involved twenty-four postgraduate students as experimental subjects. The teaching intervention comprised high-fidelity simulation combined with the team-based learning (TBL) method. Notably, all participants were new to this combined approach, having previously been exposed to traditional teaching methods. We measured total learning performance with a pre-post design. Subsequently, semi-structured interviews were employed, and data analysis followed Colaizzi's methodology. NVivo 12.0 was used to code and analyze interview records.

Results

The high-fidelity simulation + TBL teaching method led to significant improvements in clinical operation scores, including hands-on CPR (80.95 ± 5.81 vs 88.46 ± 7.35), endotracheal intubation (76.03 ± 6.51 vs 81.89 ± 9.72), defibrillation (79.96 ± 4.37 vs 89.84 ± 3.98), and team collaboration (28.33 ± 2.46 vs 32.99 ± 2.85) (P < 0.05). Additionally, a comprehensive qualitative analysis identified 10 core themes, which could be grouped into four thematic clusters: "Reflection and feedback," "Highly simulated clinical scenario," "Improving clinical thinking," and "Teamwork and communication."

Conclusion

The integration of high-fidelity simulation and TBL enhances teaching efficiency and overall clinical emergency response capabilities for postgraduate students, offering structured small group learning applicable to standardized pediatric CPR training.

Clinical teaching

High-fidelity simulation

Team-Based Learning

Pediatrics

Postgraduates

Cardiopulmonary resuscitation (CPR) is a critical emergency intervention for cardiac arrest, essential for saving lives and improving patient outcomes. Studies indicate a low CPR success rate in China, with a mere 1.6% survival rate [1], in stark contrast to 9% in the United States and 18% in Europe[2]. It's very thought-provoking. One of the main reasons for the low CPR success rate in China is CPR training coverage in China ranges from 1–5%, significantly lower than the over 30% coverage in developed nations [3]. Given the overall lack of CPR training in society, Standardized CPR training is very imperative to bolster widespread CPR adoption. Furthermore, as medical graduate students, proficiency in CPR techniques is required.

Due to the critical nature of cardiac arrest, making full use of every minute is crucial in patient rescue, posing challenges for on-site teaching[4]. Cardiac arrest, being an unpredictable event, hinders students' continuous learning and practice compared to chronic diseases, impacting knowledge and skill acquisition. Simulation-based education has emerged to create a near-real clinical environment, employing high-fidelity simulation to replicate physiological and pathological changes in pediatric patients and response to interventions [5]. This method replicates the complete CPR process for patients in cardiac and respiratory arrest, ensuring higher practice repeatability [6]. Research indicates high-fidelity simulation effectively enhances students' clinical skills and knowledge translation, which improve teaching quality[7].

The traditional CPR training method has primarily focused on improving individual skills, neglecting team cooperation training, which has significantly impacted the effectiveness and timeliness of the rescue process. Since its inception in 2001, the team-based learning (TBL) teaching method has been widely adopted by medical schools globally and has gained recognition within the international educational community [8, 9]. Lo BM et al. [10] demonstrated that students exposed to the TBL teaching method exhibit enhanced problem-solving abilities, enabling them to concentrate on team-based observation of critically ill children's diseases and fostering long-term career development.

Recent studies have reported positive outcomes from high-fidelity simulation in surgical and medical clinical teaching [11]. However, there is limited literature on the combined use of high-fidelity simulation and TBL in pediatric graduate student education. This study aims to evaluate the effectiveness of the SimMan high-fidelity simulation system combined with the TBL teaching method for pediatric graduate students, providing valuable teaching experience and a theoretical foundation for the development of pediatric graduate education.

Study object

This is a quantitative and qualitative study. The study sample was the grade 2021 and 2022 graduate students of the Seventh Affiliated Hospital of Sun Yat-sen University, and a total of 24 students were randomly selected as the experimental subjects. Among them, 11 were male students, accounting for 45.8%; There were 13 female students, accounting for 54.1%. All participants were between 21 and 24 years old, with a mean age of 22.1 ± 1.5 years.

Teaching implementation

In terms of teaching methods, this study adopted high-fidelity simulation combined with TBL teaching method. By implementing a strategy of self-comparison before and after, All students were required to be assessed for clinical skills by means of an examination before and after receiving the high-fidelity simulation + TBL teaching method. (Note: It is worth noting that all the students involved in the study had not been exposed to the high-fidelity simulation combined with TBL teaching method before, and they had been using the traditional teaching method for learning. )

Implementation process of the high-fidelity simulation combined with TBL teaching method: The specific implementation steps of high-fidelity simulation + TBL teaching method were as follows:

(1) Pre-class preparation (self-study based): The "2015 AHA Guidelines for CPR and ECC" pediatric CPR materials, manual defibrillator usage materials, and related videos were distributed to students for sharing skill operation knowledge and role rotation with group members. Teachers would then conduct skill drills and provide guidance on key knowledge points.

(2) Pre-class preparation: Teachers distributed typical teaching cases of pediatric cardiac arrest to the students, informing them of the course schedule and learning objectives, setting questions for students to preview before class, and students freely forming resuscitation teams (6 persons in total, playing roles of the leader, airway manager, chest compression manager, defibrillation manager, intravenous line manager, and recorder).

(3) An experienced teacher guided the teaching, explaining the overview of the simulation case, informing all students of the key points when using the high-fidelity simulation system to demonstrate the entire treatment process, and answering students' questions. The 6-person resuscitation team formed by Group 1 performed first, with roles allocated, and the teacher emphasizes role distribution again.

(4) Other students carefully observed the entire resuscitation process of these 6 students, taked detailed notes, and considered any deficiencies in the process.

(5) After 5 rounds of CPR, the teacher organized the 6 students from the resuscitation team to discuss which parts of the rescue process were well implemented and which parts needed to be improved, with each student expressing their opinion.

(6) The teacher then organized other students who observed from the side to share their views on the entire rescue process.

(7) The teacher summarized and integrated the discussion results, improvements, and measures from each group, followed by the 6 students from the resuscitation team performing a complete round of resuscitation based on the discussion and rectification suggestions.

(8) The teacher graded the performance, finally pointing out common mistakes and shortcomings of the students and providing detailed and specific guidance.

The traditional teaching method:

(1) Theory teaching: the teaching process of "preview-listening-review-examination" is based on teacher's instruction. The teachers taught according to the teaching requirements of children's CPR. Before the teaching, the relevant problems were assigned to the graduate students in advance, and the students were divided into groups by themselves.

(2) Skill practice: two students/group worked together to practice children's double-operation cardiopulmonary resuscitation (chest compression + bag-mask ventilation) and manual defibrillator use (electrocardiogram recognition + defibrillator energy selection). Each set was trained 5–6 times for about 60 minutes.

Data collection and Evaluation methods

(1) Skill assessment of all students: mainly to check the proportion of effective chest compressions within 5 minutes and the teamwork of the group, while also assessing each student's CPR skills, including chest compressions, use of manual defibrillators, and bag-mask ventilation, followed by scoring.

(2) Theoretical exam: A closed-book exam consisting of 20 single-choice questions and 10 clinical case questions. Summary was presented in Fig. 1.

(3) To evaluate the effectiveness of the high-fidelity simulation + TBL teaching method, face-to-face interviews were conducted post-study by experienced qualitative researchers in a quiet hospital office. A total of eleven participants were interviewed until data saturation was achieved [12]. Each interview, recorded in MP3 format, focused on participants' experiences during the CPR course. Additional questions were tailored based on individual responses. See Table 1 for example interview questions.

Table 1

Examples of key interview questions.
	Interview questions
1	What specific learning experiences did you have with high-fidelity simulation and Team-Based Learning (TBL) during the CPR course?
2	Were other teaching methodologies used during the CPR course? If so, which ones do you prefer and why?
3	How did you feel about preparing to use high-fidelity simulation and TBL during the CPR course?
4	Can you share a beneficial experience you had with TBL?
5	Reflect on any challenging experiences with high-fidelity simulation and TBL during the CPR course.?
6	What notable changes did you notice in your learning experience before and after using high-fidelity simulation and TBL during the CPR course?
7	What significance did high-fidelity simulation and TBL have for you during the CPR course?

Statistical Analysis

Data analysis was performed using SPSS 23.0. Descriptive statistics for continuous data were presented as mean ± standard deviation (͞x ± s), analyzed using t-tests. Categorical data, presented as frequency and percentage (n(%)), were analyzed with chi-square tests. Significance was set at P<0.05.

Data analysis followed Colaizzi’s phenomenological method [13]using NVivo 12 Plus software. Initially, transcripts were reviewed to extract relevant statements on the high-fidelity simulation + TBL teaching method in cardiopulmonary resuscitation. Redundant expressions were eliminated, and statements were abstracted to understand participants' intent and significance. Themes and clusters were then derived from these statements. The findings were presented comprehensively, including detailed explanations and raw data. Finally, consistency was verified with the participants by presenting themes, clusters, and citations.

To ensure rigor, we followed a structured process [14], establishing credibility by confirming and describing themes with participants. We obtained in-depth data, accurately described the phenomenon, and ensured transferability. Interview details were recorded via field notes and memos, with all data transcribed for reliability. The qualitative researcher practiced reflexivity during interviews to minimize bias. Additionally, each investigator independently analyzed data to identify inconsistencies before reaching consensus on the final results.

1. Quantitative analysis

Quantitative analysis revealed significant improvements in students' skill assessment scores (CPR, intubation, defibrillation) and scenario-based assessments post high-fidelity simulation + TBL teaching method (P < 0.05) (Table 2). Additionally, scores on theoretical and clinical case multiple-choice questions significantly improved after the intervention (P < 0.05). See Table 2 for details. Post-training questionnaire survey results indicated students excelled in pediatric CPR knowledge, clinical problem-solving, theory-practice integration, comprehensive skills, and teamwork (Table 2).

Table 2

Assessment of the two groups of learners
	Before accepting high-fidelity simulation + TBL	After accepting high-fidelity simulation + TBL	P value
Hands-on CPR
Operational Score (points, x ± s )	80.95 ± 5.81	88.46 ± 7.35	< 0.05
One-time Pass (%)	10 (83.3%)	11 (91.7%)	> 0.05
Endotracheal Intubation
Operational Score (points, x ± s )	76.03 ± 6.51	81.89 ± 9.72	< 0.05
One-time Pass (%)	8 (66.7%)	10 (83.3%)	> 0.05
Defibrillation
Operational Score (points, x ± s)	79.96 ± 4.37	89.84 ± 3.98	< 0.05
One-time Pass (%)	9 (75.0%)	11 (91.7%)	> 0.05
Illness Recognition	23.94 ± 6.68	27.52 ± 7.35	< 0.05
Implementation of Rescue Plans	30.48 ± 5.53	39.02 ± 6.01	< 0.05
Team Collaboration	28.33 ± 2.46	32.99 ± 2.85	< 0.05
Overall Score	84.35 ± 8.92	94.01 ± 6.23	< 0.05
Personal theoretical multiple-choice question score (points)	80.12 ± 2.45	82.43 ± 4.97	0.17
Clinical case multiple-choice question score (points)	78.34 ± 3.86	84.91 ± 6.01	0.001

2. Qualitative analysis

The results were presented through four theme clusters and nine themes, and the theme clusters were as follows: reflection and feedback, highly simulated clinical scenarios, improving clinical thinking, teamwork and communication (Table 3).

Table 3

Themes and theme clusters
Theme clusters	Themes
Reflection and feedback	Rich theoretical knowledge Switch roles Increase diversified case training Strong sense of participation
Highly simulated clinical scenarios	Memorable experience; Strong sense of participation
Improving clinical thinking	Clinical skills improvement The combination of theory and practice
Teamwork and communication	Clear division Complementary collaboration

2.1 Reflection and feedback

Participants were inspired by the integral role of reflection and feedback in TBL, which fueled their commitment to effective learning. These practices also fostered a supportive and positive learning environment for the entire class.

2.1.1 Rich theoretical knowledge

90.9% of students believed that possessing 'rich theoretical knowledge' would enhance their TBL proficiency. This recognition prompted them to preview before class, as preparation was mandatory for TBL, fostering consistent study habits they valued.

If there is no reserve or preparation of certain basic knowledge, then you will suddenly do it, maybe some details may be forgotten, you include what injection of renal gland ah, how much, if not often contact this, maybe its dose ah, all aspects may not be controlled, and then it may lead to a little messy feeling, But I feel like if you have a preview in advance. (Participant 1)

Like us, if we do experiments out of clinical practice, after a year or two, it may be almost completely forgotten. If you directly start it, it may be a little bewildered, such as for example, the amount of what he that on-line may be a little unclear, or a little bit confused, this may be if the previous preparation time is more, or maybe it's better if we do a little training. (Participant 3)

2.1.2 Switch roles

Participants acknowledged the positive impact of implementing clear role division and rotation in TBL, noting that it significantly elevates team dynamics. Through defined responsibilities and rotational tasks, team members cultivate cooperation, deepen mutual understanding, and ultimately enhance overall team effectiveness.

If there was a systematic, well, we could do it once for each position, maybe everyone's comprehensive ability would be improved. (Participant 8)

In fact, I can change roles, because I practiced twice and then changed roles, in fact, each role can learn different things. (Participant 9)

2.1.3 Increase diversified case training

Half of the students recognized the significant benefits of augmenting clinical cases in high-fidelity simulation + TBL projects, noting improvements in professional competence along with enhanced teamwork, communication, and responsiveness skills.

I think we could put a few more of those different forms of, um, cases that are different, in different situations, because it's in different situations, some of the points of it are still different, um, so I think we could put a few more of those, um, different directions, or difficult cases and that kind of thing, and it would be better for us clinically in the future, It's more impressive. (Participant 6)

2.1.4 Strong sense of participation

The project offered students a valuable opportunity to develop a deep appreciation for teamwork and personal accountability. Each student's pivotal role and enthusiastic involvement significantly contributed to the project's seamless execution.

It is a feeling that there is a team, and then the division of labor is relatively detailed. Then, everyone is responsible for a piece, and in addition to thinking about their own steps, but also to do a coordination and communication with the team, I feel that my own thinking at the same time, also increased a team's awareness. (Participant 2)

2.2 Highly simulated clinical scenarios

The high-fidelity simulator is invaluable in medical education, providing a lifelike learning environment that effectively prepares students for successful careers in healthcare. Through its simulation of diverse clinical scenarios, it seamlessly connects theoretical knowledge with practical application, empowering students with the necessary skills and confidence for their future roles as medical professionals.

2.2.1 Memorable experience

Participants enthusiastically described their experience in the high-fidelity simulation + TBL program as unforgettable. The lifelike clinical scenarios recreated by the high-end simulator immersed them in dynamic rescue situations, leaving a lasting, positive impression.

Because I do not know what the actual clinical situation is before, I think this method can be basically complete, can not say completely, it may have been very close to the actual situation. It is also of great help to the practical application of clinical practice. (Participant 7)

This way of learning can be profound. This time, it is equivalent to me giving you a scene, which is more suitable for our clinical practice. (Participant 11)

2.3 Improving clinical thinking

High-end simulation, with its diverse clinical cases, offers crucial practice for medical students, refining their clinical thinking.

2.3.1 Clinical skills improvement

Participants reported continuous improvement in clinical skills and thinking ability through extensive case training.

You treat him as a real patient, and then in the whole process, you will repeatedly think about what causes any situation, so that your clinical thinking has been comprehensively improved. (Participant 10)

2.3.2 The combination of theory and practice

Participants found the high-end simulator, with its diverse cases and scenarios, beneficial for integrating theory into practice and enhancing clinical skills.

If I encounter this similar situation again, I can deal with it more properly. Especially for someone who has been in clinical practice for a short time, I can better connect my theoretical knowledge with clinical practice through this training. (Participant 8)

2.4 Teamwork and communication

In TBL, each participant's role and effective communication among members contribute to project success, nurturing teamwork and communication skills.

2.4.1 Clear division

Participants widely appreciate the clarity of individual responsibilities in TBL, enhancing the smoothness of the learning process.

That is to say, if this situation really happens in our real hospital, we as a team, everyone has a division of labor, everyone in an orderly manner to carry out their own project is quite good, is if this situation really occurs, such as if you have participated in this age, may be more comfortable. (Participant 3)

2.4.2 Complementary collaboration

Participants expressed enhanced mastery of diverse clinical skills within the TBL teaching model, attributing it to collaborative teamwork and mutual learning among team members.

I prefer this kind of teamwork mode. Still learned a lot, well, very efficiently. (Participant 4)

Despite China's low CPR penetration rate (1%-5% compared to over 30% in developed countries)[3], Standardized CPR training is necessary to promote the widespread adoption of CPR. In addition, as a medical graduate student, proficiency in cardiopulmonary resuscitation techniques is required. Therefore, it is very essential to study how to use effective teaching methods to improve the ability of graduate students to perform CPR.

In this study, quantitative research evaluated the combined impact of high-fidelity simulation and TBL on CPR training outcomes, demonstrating significantly improved theoretical scores, situational assessment, rescue plan implementation, teamwork, and CPR proficiency in the high-fidelity simulation and TBL group compared to traditional teaching. These were consistent with the results reported on high-fidelity simulation in the literature. High-fidelity simulation provided accurate feedback on operation quality, standardized scenes, and facilitated continuous skill enhancement [15]. It underscores educators' clinical expertise, optimizing teaching schedules and elevating their professional prowess. The immersive nature and prompt feedback of high-fidelity simulation facilitate a seamless transition from theory to practical skills, promoting adherence to medical ethics [16, 17]. TBL teaching method is used to teach in small groups, which is conducive to improve the feedback speed [18], active classroom atmosphere, improve students' learning enthusiasm, improve classroom efficiency, so as to significantly improve the theoretical and operational assessment results [19]. High-fidelity simulation combined with the TBL teaching method in teaching of cardiovascular emergency shows obvious advantages, the use of the teaching method for cardiovascular emergency teaching the students theory and skills examination is superior to the traditional teaching of the students [20].

Qualitative research indicated positive student response to high-fidelity simulation and TBL in our study. Students found high-fidelity simulation and TBL to offer a practical, clear, and effective learning environment. Students reported high-fidelity simulation and TBL motivated active participation in a collaborative, non-hierarchical setting. In this mode, each member leverages their strengths to contribute to team development. Yet, students acknowledged their responsibility for assigned duties during discussions. This underscores the collaborative responsibility, enabling each member to play an active role. Additionally, high-fidelity simulation and TBL fosters student literacy in listening, respecting, and understanding peers, fostering a harmonious learning environment. This was consistent with the results reported in the literature. Implementation of high-fidelity simulation and TBL within small group settings accelerates feedback cycles, ignites student enthusiasm, and enhances overall classroom efficiency, resulting in notable advancements in both theoretical comprehension and hands-on proficiency [20, 21]. Implementing TBL in teaching anaphylactic shock, obstetrics, and advanced cardiovascular life support for interns displayed positive outcomes [22]. After we interviewed the students, we obtained five themes, which will be discussed in the following.

Firstly, up to 90.9% of students agreed that 'reflection and feedback' enhance comfort and deepen understanding in the study. This was consistent with the results of previous studies. Burgess A et al. [18] reported that TBL teaching method was team-based, and many people in the group discuss, which improved students' feedback and reflection ability, and helped to deepen students' understanding and memory. Two recent studies, according to the results of the TBL teaching method is very effective teaching method, help students to actively participate in discussion, increase the speed feedback, to deepen the understanding of knowledge [23, 24]. Exam preparation under a responsibility system promotes a positive learning attitude. TBL increases student time investment compared to traditional classes, fostering reflective and self-directed learning habits during tests. TBL participants jointly create a positive learning atmosphere [25].

Secondly, 81.8% of participants emphasized the value of highly simulated clinical scenarios in our study. These scenarios, offered in high-fidelity simulation, closely resemble real-world healthcare settings, ranging from simple to complex cases. They enhance problem-solving skills and prepare students for dynamic healthcare environments. High-fidelity simulation could enable students to practice clinical skills on virtual patients, reducing the risk to real patients and fostering confidence and empathy. This was similar to the results of previous studies. Macnamara AF et al.[26] reported that a high-fidelity patient simulator, in a simulated clinical environment, was of greater value to their preparation for clinical practice. A recent meta-analysis showed that Learners using high-fidelity simulation more significantly benefited from the advanced life support training in terms of knowledge and skill performance at the course conclusion [27].

Thirdly, all participants agreed that combining high-fidelity simulation with TBL teaching effectively integrates theory and practice, aiding in knowledge consolidation and enhancing clinical thinking in our study. Students noted the realism of simulated scenarios during TBL sessions. Results show TBL positively impacts student attention and classroom effectiveness [28]. TBL incorporates reading materials, real-time assessment, and feedback to reinforce core concepts, while practical activities enhance critical thinking and problem-solving skills in real-world scenarios [29]. Previous studies confirm TBL's effectiveness in core concept understanding, classroom concentration, and identifying knowledge gaps [30].In practical activities, students develop decision-making skills, support their reasoning with evidence, and engage in team-based discussions to enhance critical thinking [31]. This approach fosters classroom immersion through realistic case scenarios and cultivates critical thinking during focused team discussions. TBL, a structured learning process where students systematically engage with core concepts across multiple phases, has been praised for its constructive nature [28]. Studies have shown its significant impact, aiding students in ongoing learning during assignment and exam preparation [32].

Finally, 72.7% of students believed that participating in TBL improved their communication and collaboration skills in this study. In TBL, students engage in complementary cooperation, fostering mutual learning by recognizing each other's needs [31]. The basic modules of TBL stimulate student engagement and teamwork[31]. Considering their contributions to exams and teamwork, students develop a sense of responsibility, promoting continuous learning [33]. Prior research shows students spend more time studying as they prepare for team activities [33]. Teamwork enhances student participation, interaction, and fosters respectful relationships [34]. Team collaboration in TBL builds trust, develops dynamics, and prepares students for professional success [33]. Interprofessional TBL benefits students in nursing, medicine, and physical therapy, enhancing their future collaboration skills [31, 35, 36].

Limitations

The limitations of this study should be acknowledged. Firstly, this article reports on a single pilot educational experience at a single institution. Future studies could expand the number of students, collaborate with multiple medical colleges, and reduce the bias of research results. Secondly, students might have had different educational backgrounds and grown up in different environments. This may have affected the accuracy of assessment. Future research could add information about education background and growth environment. Finally, we measured total learning performance with a pre-post design. This means there is always a risk of students‘learning the test.’

In conclusion, the integration of high-fidelity simulation with Team-Based Learning (TBL) significantly enhances teaching efficiency and boosts the clinical emergency response capabilities of postgraduate students. TBL, serving as an active and structured small group learning approach, proves highly effective for standardized cardiopulmonary resuscitation (CPR) training in pediatric postgraduates, offering substantial benefits.

Funding:

This study was supported by application of teacher-standardized patients combined with case-guided teaching method in pediatric probation teaching of Sun Yat-sen University Undergraduate Teaching Reform and Teaching Quality Project in 2020 (Educational Affairs of Sun Yat-sen University [2020] No. 93), application of TBL combined with case-based learning in the integration of online and offline teaching in pediatrics higher education teaching reform project of Guangdong Province in 2020, 2020 University-level undergraduate Quality Engineering and Teaching Reform research project "Application of TBL Combined with Case Teaching in Pediatric Undergraduate Clinical Practice Teaching” (No. 80000-31911130); 2020 Higher Education Teaching Reform Project of Guangdong Province (No. : Guangdong Education Gao Han [2020] No. 20), 2023 Teaching Reform Project of Guangdong Province "New Medical Science" Teaching Commission (Serial number: 78), Sun Yat-sen University 2020 Undergraduate Teaching Reform and Teaching Quality Engineering Project (No. : Sun Yat-sen University Educational Affairs (2020) No. 93).

Author Contribution

This study was designed by LL Xu, C Chen and YL Tang. All Pre-class preparatory work were designed and performed by LL Xu, and YL Tang. Assessment, data analysis and interpretation were performed by LD Zhang, L Wang and YL Li. LD Zhang, LL Xu, YL Tang and YT Li provided the supervision, funding, and administrative support. YY Guo, HX Lin, XT Ye and HB Chen was responsible for literature search and data collection. LL Xu, C Chen, LD Zhang, L Wang, and YL Li wrote and edited the manuscript. The authors have read and approved the final manuscript.

Acknowledgement

The authors are grateful to the graduate paediatric students of the Seventh Affiliated Hospital of Sun Yat-sen University from 2021 to 2022 for participating in the study.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

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Effectiveness of Integrating High-fidelity Simulation and Team-Based Learning in Pediatric postgraduates CPR Training: A Mixed Method Running Head：High-fidelity Simulation and TBL

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