ORIGINAL RESEARCH

Rapid Cycle Deliberate Practice Training for Simulated

Cardiopulmonary Resuscitation in Graduate Medical Education
Jaron D. Raper, MD* *University of Alabama at Birmingham, Department of Emergency Medicine,
Charles A. Khoury, MD* Birmingham, Alabama
Anderson Marshall, MD† †
University of Alabama at Birmingham, Department of Internal Medicine,
Robert Smola, MD† Birmingham, Alabama
‡
Zachary Pacheco, MD* University of Alabama at Birmingham, Department of Biostatistics,
Jason Morris, MD† Birmingham, Alabama
Guihua Zhai, PhD‡ §
University of Alabama at Birmingham, Department of Pediatrics, Birmingham, Alabama
Stephanie Berger, MD§
Ryan Kraemer, MD†
Andrew Bloom, MD*

Section Editors: David Thompson, MD, and Dan Mayer, MD

Submission history: Submitted March 3, 2023; Revision received November 21, 2023; Accepted November 27, 2023
Electronically published xxxx 0, 2024
Full text available through open access at http://escholarship.org/uc/uciem_westjem
DOI: 10.5811/westjem.60319

Background: Simulation-based medical education has been used in medical training for decades.
Rapid cycle deliberate practice (RCDP) is a novel simulation strategy that uses iterative practice and
feedback to achieve skill mastery. To date, there has been minimal evaluation of RCDP vs standard
immersive simulation (IS) for the teaching of cardiopulmonary resuscitation to graduate medical
education (GME) learners. Our primary objective was to compare the time to performance of Advanced
Cardiac Life Support (ACLS) actions between trainees who completed RCDP vs IS.

Methods: This study was a prospective, randomized, controlled curriculum evaluation. A total of 55
postgraduate year-1 internal medicine and emergency medicine residents participated in the study.
Residents were randomized to instruction by RCDP (28) or IS (27). Stress and ability were self-assessed
before and after training using an anonymous survey that incorporated five-point Likert-type questions.
We measured and compared times to initiate critical ACLS actions between the two groups during a
subsequent IS.

Results: Prior learner experience between RCDP and IS groups was similar. Times to completion of the
first pulse check, chest compression initiation, backboard placement, pad placement, initial rhythm
analysis, first defibrillation, epinephrine administration, and antiarrhythmic administration were similar
between RCDP and IS groups. However, RCDP groups took less time to complete the pulse check
between compression cycles (6.2 vs 14.2 seconds, P = 0.01). Following training, learners in the RCDP
and IS groups scored their ability to lead and their levels of anticipated stress similarly (3.43 vs 3.30,
(P = 0.77), 2.43 vs. 2.41, P = 0.98, respectively). However, RCDP groups rated their ability to participate
in resuscitation more highly (4.50 vs 3.96, P = 0.01). The RCDP groups also reported their realized stress
of participating in the event as lower than that of the IS groups (2.36 vs 2.85, P = 0.01).

Conclusion: Rapid cycle deliberate practice learners demonstrated a shorter pulse check duration,
reported lower stress levels associated with their experience, and rated their ability to participate in ACLS
care more highly than their IS-trained peers. Our results support further investigation of RCDP in other
simulation settings. [West J Emerg Med. 2024;25(2)1–8.]

Volume 25, No. 2: xxxx 2024 1 Western Journal of Emergency Medicine

Rapid Cycle Deliberate Practice to Teach Resuscitation Raper et al.

INTRODUCTION Population Health Research Capsule

Despite advances in resuscitation science and training,
cardiac arrest remains the third leading cause of death in the What do we already know about this issue?
United States.1 Millions of clinicians receive Basic Life Rapid cycle deliberate practice (RCDP) is a
Support (BLS) and Advanced Cardiac Life Support (ACLS) simulation strategy that uses iterative
training, yet patients’ survival rates vary considerably.2,3,4 practice and coaching to achieve skill mastery
Immediate recognition of cardiac arrest, high quality and is effective in procedural instruction.
cardiopulmonary resuscitation (CPR), and timely
defibrillation are the mainstays of care.5,6 Effective education What was the research question?
is crucial to execute these principles, improve team Is RCDP or immersive simulation more
performance, and enhance outcomes.7 effective in training residents to perform
Simulation-based medical education (SBME) is well cardiopulmonary resuscitation (CPR)?
established in medical training and graduate medical
education (GME). In SBME, learners gain experience from a What was the major finding of the study?
realistic clinical scenario without the possibility of causing RCDP shortens pulse checks, and learners
harm to a patient.8 Learners are given the freedom to develop report less stress and greater confidence
skills through practice and gain valuable feedback via performing CPR.
debriefing. As a result, SBME has been associated with
improved skill development and patient outcomes.9,10,11 How does this improve population health?
Rapid cycle deliberate practice (RCDP) is an innovative Resuscitation instruction based in RCDP AQ2
simulation strategy that uses iterative practice and feedback shows promise as a tool to enhance residents’
to achieve skill mastery. Developed from Anders Ericsson’s mastery of lifesaving CPR skills.
work on deliberative practice, RCDP allows for advanced
learning through repetition and skill refinement.12 It was
originally described by Hunt in 2014 and implemented in
pediatric resuscitation training.13 In RCDP, learners begin a identifying it as an educational strategy warranting further
simulated scenario, but in contrast to the classical post- research.7 Despite this call to action, there has been a paucity
simulation debrief, the case is frequently paused by the of literature evaluating RCDP in ACLS training for the care
instructor. Each break serves as an opportunity for corrective of adult patients, regardless of learner type.20 We sought to
instruction, coaching, feedback, and subsequent address this knowledge gap through the evaluation of RCDP
supervised repitition.13 for ACLS as it is applied to postgraduate year (PGY)-1
Over the last decade there has been an increased focus on residents in GME. We did this through a comparison of time
RCDP training in resuscitation, with most studies focused on to completion of critical ACLS actions between RCDP and
pediatric trainees.13,14 When compared to the standard IS groups (our primary objective). As a secondary objective,
immersive simulation (IS) approach, RCDP has we compared resident perceptions between RCDP- and
demonstrated shorter time to initial chest compression and IS-trained groups.
defibrillation in pediatric medicine trainees, improved chest
compression fraction in adult medical trainees, and better METHODS
skill retention.13,14,15,16 Even more recently, we have seen Study Design
RCDP implemented into procedural training where it has In July 2022, we conducted a prospective, randomized,
also demonstrated positive learner outcomes. Groups trained controlled study approved by the institutional review board.
in RCDP demonstrated better preparedness for intubation
and post-procedure care in pediatric airway management.17 Setting and Participants
Similarly, RCDP-based training has been suggested for the The study was conducted in an accredited simulation
donning and doffing of personal protective equipment, and center that is part of a large academic teaching hospital and
our obstetric colleagues have proven its utility for forceps- involved 43 internal medicine (IM) and 12 emergency
based deliveries.18,19 medicine (EM) PGY-1 residents who had obtained ACLS
Instruction based in RCDP has strong evidence to support certification in the two weeks preceding this study. No other
its use in areas of medical education that are algorithmic in coaching or instruction regarding the care of a pulseless
nature, and/or require a high degree of procedural skill. The patient was provided prior to study implementation. All 55
American Heart Association (AHA) recognized this as residents participated voluntarily in the study. Faculty
recently as 2020, recommending that deliberate practice be facilitators of all simulation sessions were IM and EM faculty
incorporated into BLS and ACLS training, simultaneously who were board certified in their respective fields. Each

Western Journal of Emergency Medicine 2 Volume 25, No. 2: xxxx 2024

Raper et al. Rapid Cycle Deliberate Practice to Teach Resuscitation

facilitator underwent formal IS- and RCDP-facilitator participation. Each measure was assessed using a five-point
training prior to involvement in the study. Facilitators were Likert-type scale.
not blinded to the study objectives.
Immersive Simulation Protocol
Protocol All IS teams were provided with the same scripted pre-
In the week prior, residents were provided with a brief, which described the basic tenets of simulation and
description of the study and an electronic copy of the informed participants that they would be caring for a
informed consent document to allow for a detailed and pulseless patient. Teams were not instructed regarding the
private review. Each of the 55 participants then provided assignment of clinical roles but were allowed to self-assign as
written informed consent on the date of their scheduled they deemed appropriate. The IS teams were then activated
simulation event. Our study used five teams for each by an ESP functioning in the role of a nurse who brought the
instructional intervention. Each team was comprised of five participants to the care area and asked participants to
or six members who were randomly assigned to either RCDP evaluate an unresponsive patient.
or IS, for a total of 55 participants (28 in RCDP groups, 27 in Once outside the patient’s room, participants assumed
IS groups). While there was a fixed and limited number of care for the patient without further coaching or intervention.
available participants (IM and EM interns), we performed a The IS participants were permitted to navigate the patient’s
post-hoc power analysis to establish a basis for future work. case without interruption, while physician facilitators
With an α = 0.05, this study had 29% power to detect a large observed their actions from a simulation control room with
effect size (d = 1) for primary outcomes and 71% power to audio and visual surveillance of the simulation area. The IS
detect a medium effect size (w = 0.3) for secondary outcomes learners were allowed to navigate their case without
(G*Power 3.1.9.7). We used an online randomization interruption until the fourth pulse check or until 30 minutes
generator (https://www.randomizer.org/) to divide had elapsed, at which time facilitators initiated return of
participants into 10 teams, with five teams for each spontaneous circulation and the case was terminated. Given
instructional method. the nature of the IS educational sessions, learners did not
Due to scheduling differences, IM and EM participants have the opportunity to rotate roles. Learners then returned
were separated and completed their respective experiences on to the briefing room, and physician facilitators debriefed
different days. The IM faculty facilitated all IM resident based on observed performance according to a standardized
sessions. To minimize confounding related to the debriefing guide and until total case time reached 45 minutes.
effectiveness of the individual facilitator, the two IM faculty The guide emphasized coaching regarding resuscitation and
facilitators led both the RCDP and the IS sessions for the IM time-sensitive interventions that matched the primary
residents. The 12 EM participants completed their experience outcome measures (eg, time to identification of pulselessness,
the following week in two teams of six, one of which was time to initiation of chest compressions, etc).
assigned to RCDP and the other to IS. The EM faculty
facilitated both EM resident sessions. All faculty facilitators RCDP Simulation Protocol
were trained in implementation of RCDP and IS. This All RCDP groups were given a standard pre-brief that
training was provided by certified healthcare simulation described the basic tenets of simulation. Groups were then
instructors in our internationally accredited institutional provided with an introduction to the simulation modality
simulation center. No faculty facilitators were involved in the assigned to them. Teams were not instructed regarding the
extraction of performance data. assignment of clinical roles but were allowed to self-assign as
The same two embedded simulation participants (ESP) they deemed appropriate. The RCDP teams were activated
functioned as nurses for all sessions. The ESPs in all sessions by an ESP who brought the participants to the care area and
were registered nurses and certified healthcare simulation asked them to evaluate an unresponsive patient while
educators employed by our institutional simulation center. physician facilitators observed at the bedside. The RCDP
The ESPs were instructed to assist only with care tasks when groups rotated roles, allowing them the opportunity to direct
directly asked for specific task assistance (eg, locating care the resuscitation and receive feedback.
items) but did not trigger initiation of individual task In addition to their standardized training, all facilitators
completion or provide guidance on task performance. were provided with an RCDP coaching guide, which was
Following informed consent, learners were asked to focused on the same resuscitation and time-sensitive
complete a pre-simulation survey to establish baseline interventions as the immersive case debriefing guide.
learner characteristics. The survey queried each participant’s Facilitators provided real-time coaching and feedback based
prior level of experience as well as self-perceived ability to on the RCDP coaching guide. Cases were then restarted,
lead and participate in the care of a pulseless patient. The rewound, or resumed according to facilitator discretion.
surveys also assessed the learner’s anticipated and prior Total learner simulation and debriefing time was 45 minutes
experienced stress associated with code leadership and for each RCDP case.

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Rapid Cycle Deliberate Practice to Teach Resuscitation Raper et al.

Protocol Overlap effectiveness of their experience (1 not at all effective,

Upon completion of debriefing and closure of their 5 extremely effective). Finally, learners were asked to rate the
respective cases, all participants returned to the briefing stress level they perceived to be associated with participating
space. Maintaining separation of initial RCDP vs IS groups, and leading their simulated experience (1 not at all stressful,
a subsequent IS session was completed by all participants to 5 extremely stressful).
during which audio and visual recordings were obtained.
Data abstraction of times to completion of critical ACLS Statistical Analysis
actions was obtained from this session. Participants were First, we compared prior simulated and genuine CPR
activated a second time by the ESP to care for an additional, experiences as leader and as participant for RCDP and IS
unresponsive patient. Learners were allowed to role assign groups, using the Cochran-Mantel-Haenszel test, given the
and complete the case without intervention from the ESP ordinal nature of the Likert-type scale. We defined simulated
or facilitator. experiences as those involving CPR training that did not
involve the care of a patient. Genuine experiences were
Primary Outcome Measures defined as those involving the CPR-based resuscitation of a
Time to completion of critical actions was used as a coding patient. We then compared the time-based
surrogate for proficiency in the performance of an ACLS- differences between RCDP and IS groups using a Student
based resuscitation. These critical actions were defined by t-test or a Wilcoxon test when there was substantial deviation
research team consensus after reviewing ACLS protocols. from normality. Our sample size for all primary outcome
Time zero was determined based upon learner entry into the measures was 10 teams. We compared mean time differences
care area, and times to completion of resuscitative time- between the two groups for first pulse check, first chest
based interventions were extracted through video review by compression, pause duration, backboard placement,
the primary investigator. To mitigate bias from faculty defibrillator pad placement, first rhythm analysis, first
working with their own residents, data abstraction from defibrillation, first epinephrine administration, and
video recordings was performed by the primary investigator, amiodarone administration.
who was not involved in simulation session facilitation. The Our sample size for all secondary outcome measures was
primary investigator was blinded to RCDP vs IS group 55 individuals. We also compared pre- and post-training
assignment at the time of data abstraction. Times from room survey data between the two groups using the Cochran-
entry to first pulse check, first chest compression, backboard Mantel-Haenszel test given the ordinal nature of the Likert-
placement, defibrillator pad attachment, initial rhythm type scale. The learner’s experience as code leader and
analysis, initial defibrillation, initial epinephrine participant and overall effectiveness of experience were also
administration, and antiarrhythmic administration were included in the post-training survey. Ability to lead, ability to
recorded. The duration of pause between compression cycles participate, anticipated stress leading, and anticipated stress
was also obtained for each session. participating were included in both surveys. Finally, we
compared stress leading and stress participating in pre- and
Secondary Outcome Measures post-training for both groups using a generalized Stuart-
Learners were queried using pre- and post-experience Maxwell test to evaluate the improvement after training.22
surveys, which were distributed in paper format immediately We used an alpha level of 0.05 for all statistical tests. A
before and after the simulation sessions. We developed the Benjamini-Hochberg false discovery rate adjustment was
surveys based on Kirkpatrick’s theory of educational applied for multiple comparisons. All programs were written
training and evaluation, focusing primarily on level 1 and 2 in SAS 9.4. (SAS Institute Inc, Cary, NC).
analyses.21 All survey items used a 1–5 Likert-type scale to
quantify all qualitative questions, and survey response rates
for all surveys were 100%. Prior to the educational RESULTS
intervention, learners were asked to rate their self-perceived Prior Learner Experience
ability to participate in and ability to lead a code (1 not at all Prior learner experience was similar between the groups
capable, to 5 extremely capable). They were also asked to and did not appear to be a significant confounder (Table 1).
rate their anticipated stress associated with participation and The numbers of experiences are reported as medians
leadership of a code (1 not at all stressful, to 5 extremely with minimum and maximum values due to lack of
stressful). Finally, they were queried regarding the number of normal distribution.
simulated codes they had participated in or led, as well as the
number of actual codes they had participated in or led. Primary Outcome: Time-based Differences
Following the education intervention, learners were asked Although there were trends toward shorter mean times to
to again rate their self-perceived ability to participate in and completion of critical actions for RCDP vs IS groups, we
lead a code. They were also asked to rate the overall observed only one category with a statistically significant

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Raper et al. Rapid Cycle Deliberate Practice to Teach Resuscitation

Table 1. Cardiopulmonary resuscitation experience prior Table 3. Pre-simulation mean Likert-type ratings.
to simulation.
Group Median Min Max P-value
Group Median Min Max P-value Ability to Lead IS 2 1 4 0.75
Simulation IS 1 0 17 0.34 RCDP 3 1 3
Leader RCDP 2 0 6 Ability to Participate IS 3 3 5 0.59
Genuine IS 0 0 40 0.81 RCDP 4 2 5
leader RCDP 0 0 3 Stress anticipated as IS 4 3 5 0.44
Simulation IS 3 0 50 0.46 Leader RCDP 4 3 5
participant RCDP 3.5 0 15 Stress anticipated as IS 4 2 4 0.08
Genuine IS 2 0 75 0.67 Participant RCDP 3 2 5
participant RCDP 2 0 25
IS, immersive simulation; RCDP, rapid cycle deliberate practice.
IS, immersive simulation; RCDP, rapid cycle deliberate practice.
*Genuine refers to experiences in actual patient care scenarios.
(Tables 3, 4). When we compared pre- and post-training
responses regarding anticipated stress, the anticipated stress
difference: CPR mean pause duration in seconds was 6.20 vs of future resuscitation experiences dropped significantly for
14.20 seconds (P = 0.01) in RCDP vs IS groups (Table 2). both leader and participant categories following training,
regardless of instructional method.
Secondary Outcome: Ability and Stress
For stress levels and self-reported ability, learners DISCUSSION
provided ratings on a five-point Likert-type scale. We present Learners receiving RCDP instruction showed a
the mean values in Tables 3 and 4. Prior to training, RCDP significantly shortened pause duration, reduced stress, and
and IS learners rated their anticipated stress of leading and improved self-perceived CPR skills compared to IS. The
participating in CPR similarly (4.36 vs 4.00 (P = 0.44); 3.18 RCDP instruction also shortened various time-based ACLS
vs 3.00 (P = 0.08), respectively). The RCDP and IS learners metrics, although statistical significance was not reached due
also rated their pre-training ability to lead as well as to the small sample size. A reduced pause duration carries
participate in the event similarly (2.50 vs 2.37 (P = 0.75); 3.61 notable clinical significance. Pause duration is an important
vs 3.52 (P = 0.59) (Table 3). There was no significant metric of high-quality CPR and is associated with improved
difference in the anticipated stress levels of future events patient outcomes.23,24 Reduced pause duration has a
following training, whether considering the role of leader significant impact on terminating arrhythmias and increasing
(P = 0.93) or participant (P = 0.98) (Table 4). Similarly, there return of spontaneous circulation, while increased pause
was no significant difference in experienced stress as a leader duration is associated with a decrease in survival.26
between RCDP and IS learners (P = 0.93) and the overall Although there is a paucity of literature comparing RCDP
effectiveness of the experience was rated similarly between to IS in the care of an adult patient, what little data that does
groups (P = 0.09). However, RCDP learners reported lower exist demonstrates improvements in chest compression
levels of experienced stress as a participant (P = 0.01) fraction in RCDP vs IS groups.20 Many of these prior studies

Table 2. Rapid cycle deliberate practice vs immersive simulation time in seconds.

RCDP Mean Time (±SD) IS Mean Time (±SD) P-value

First pulse check 4.00 (±1.00) 5.60 (±1.52) 0.25
First chest compression 12.40 (±3.13) 15.20 (±2.95) 0.27
Backboard placement 40.40 (±31.33) 193.40 (±183.36) 0.25
Pad placement 66.40 (±12.56) 74.80 (±20.75) 0.46
First rhythm analysis 73.60 (±13.50) 111.20 (±37.63) 0.25
First defibrillation 93.00 (±17.46) 150.60 (±63.49) 0.25
First epinephrine 131.60 (±28.75) 158.20 (±55.21) 0.41
Pause duration 6.20 (±2.07) 14.20 (±6.53) 0.01
Antiarryhthmic 376.60 (±94.25) 438.80 (±99.19) 0.41

IS, immersive simulation; RCDP, rapid cycle deliberate practice. Time is in seconds.

Volume 25, No. 2: xxxx 2024 5 Western Journal of Emergency Medicine

Rapid Cycle Deliberate Practice to Teach Resuscitation Raper et al.

Table 4. Post-simulation mean Likert-type ratings. metrics such as pad placement or administration
antiarrhythmic showed no significant change between
Group Median Min Max P-value
groups. These actions are dependent on a variety of factors in
Ability to Lead IS 3 3 5 0.77
a team focused on CPR, and as Lemke et al suggest, they may
RCDP 3 3 4 be difficult to measure effectively.15
Ability to Participate IS 4 3 5 0.01 As previously noted, our study was underpowered, which
RCDP 4.5 4 5 played a role in the absence of statistically significant
Stress anticipated IS 3 2 5 0.93 differences for many of our outcome measures. The Likert-
as Leader scale measures were better powered, as they represented 55
RCDP 3 2 4
individual survey responses as opposed to the 10 total teams
Stress anticipated IS 2 1 3 0.98
divided in two for each instructional method. For
as Participant RCDP 2 1 4 comparison, Hunt et al studied the performance of 81
Stress experienced IS 3 3 5 0.93 individual pediatric residents who participated in the post-
as Leader RCDP 3 2 5 intervention assessment and found that RCDP improved
Stress experienced IS 3 2 4 0.01 learner confidence, but there was no control group for
as Participant RCDP 2 1 3
comparison or power calculation.13 De Castro et al used five
teams for their RCDP group and four teams for their control
Overall effectiveness IS 4 3 5 0.09
group, with an 80% power to detect a 20% difference in the
RCDP 5 4 5 primary outcome. The authors found a higher chest
IS, immersive simulation; RCDP, rapid cycle deliberate practice. compression fraction and shorter times to rhythm
identification/defibrillation in the RCDP group. However,
due to data loss they were unable to achieve the planned
power.20 Lemke et al studied the greatest number of learners,
were done in pediatrics, but the results should have clinically with 102 participants in 21 teams for their control cohort, and
similar interpretations as those completed in adults.13–16 108 participants in 20 teams for their RCDP cohort and
Hunt et al conducted the only prior study examining time- found that RCDP groups demonstrated shorter times to
based metrics as a surrogate for proficiency and found RCDP defibrillation. While no formal power calculation was
to be superior for instruction of BLS interventions in junior performed, Lemke’s work appears to be the best powered
medical students.27 Our results add to this work through the thus far.15 Future work should include more robust powering
further examination of time-based metrics and learner with larger sample sizes, which will likely require inter-
perceptions. Although limited, these results lend further institutional collaboration.
credibility to the argument that RCDP may be superior to IS Another factor contributing to our inability to detect
for ACLS training. significant differences in many time-based metrics may be the
While RCDP-trained learners in our study exhibited learner level studied. By its very nature, RCDP serves as a
trends toward other favorable ACLS metrics, there were no method to develop perfect practice. Providing the learner
other statistically significant differences. Prior work has with real-time feedback and coaching builds micro-skill
demonstrated improvement in time to defibrillation, initial development and mastery, as opposed to proficiency alone.
chest compression, and backboard placement with RCDP This study focused on PGY-1 residents for two reasons. First,
training in pediatric resuscitations.13,15,20 Our work does not in an effort to avoid confounding by variations in training,
independently support these findings; however, our trends we studied PGY-1 level learners in their first month of
are in line with existing literature. residency. Second, we excluded advanced learners due to
Time to first defibrillation suggested favorability in the concerns that their involvement would confound the
RCDP group (93 vs 150 seconds [sec]), although differences study of the junior learner through advancing the
did not reach statistical significance. This distinction is performance of the entire group. Conversely, prior work that
important, however, as the RCDP group was able perform found differences in similar categories evaluated learners
this action within the AHA’s “Get with the Guidelines” from PGY levels 1–3 or studied larger learner groups.14,15,27
recommendation of first defibrillation in less than two Therefore, true skill mastery may be more attainable
minutes. Similarly, time to first epinephrine administration in through the inclusion of more advanced learners
RCDP vs IS (131 vs 158 sec), suggests reduced time in the and may contribute to more statistically significant
RCDP group without reaching statistical significance. Both results.13,15 Conversely, the inclusion of more advanced
groups performed within the five-minute metric outline from learners may influence the entire group, leading to a
“Get with the Guidelines” recommendations. As both more uniform performance. This may limit or
groups performed well with this action, obtaining statistical reduce observable differences between
significance may prove difficult. It is unclear why other instructional methods.

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Raper et al. Rapid Cycle Deliberate Practice to Teach Resuscitation

Hunt et al also notes a dose response with RCDP (ie, response rate, but due to the nature of our five-point Likert-
increasing experience and repetition fosters improved type question scale, the potential for neutral bias exists.
performance and skill mastery).13 We studied the learners’ Due to the frequent interruptions associated with the
first performance, but we did not conduct additional RCDP method, RCDP participants were able to rotate
simulated experiences beyond this. Further repetition may through each role on the resuscitation team. However, IS
have expanded differences in RCDP and IS groups. groups did not have an opportunity to change roles as a part
A common goal of simulation in medical education is to of their training, and this introduces a confounder in
reduce the stress and anxiety experienced by the learner, and comparing the learner experience as well as proficiency
this is especially true for high-stakes scenarios such as the between these instructional methods.
care of a pulseless patient. However, the simulation Finally, this study focused on time to completion of
experience can be independently stressful for learners, and critical actions but did not assess the quality of those actions,
prior work has suggested that RCDP-based instruction may including factors such as chest compression fraction (CCF).
provide an overall preferred experience. This is well However, CCF has been previously studied and found to be
illustrated by the work of Chancey et al, whose learners superior in groups undergoing RCDP-based instruction as
expressed a preference for the frequent interruptions and compared to standard IS.13,20,27
improved sense of emotional security associated with RCDP
instruction.25 Chancey’s learners also reported increased CONCLUSION
confidence in their own resuscitation skills. Our results Rapid cycle deliberate practice was favored by learners for
support these findings, demonstrating an increased ACLS-based CPR instruction, improving self-perceived
confidence in ability to participate in the RCDP groups. skills and reducing pause duration. This suggests RCDP is a
Similarly, our learners reported lower stress levels valid strategy to teach residents ACLS-based CPR and
experienced during their RCDP-based simulation. supports further investigation of RCDP in other settings.

LIMITATIONS
Due to the study’s nature, blinding participants and Address for Correspondence: Jaron D. Raper, MD, University of
AQ1
facilitators was not possible. Skill retention was not assessed, Alabama at Birmingham, Department of Emergency Medicine,
and the small sample size limits generalizability. business address, Birmingham, AL zip. Email: jdraper@uabmc.edu
Additionally, while all facilitators had undergone
Conflicts of Interest: By the WestJEM article submission agreement,
standardized training in both instructional methods,
all authors are required to disclose all affiliations, funding sources
individual facilitators may have been more effective at one and financial or management relationships that could be perceived
strategy vs the other. All participating residents completed a as potential sources of bias. No author has professional or financial
standard ACLS course in the two weeks preceding the study. relationships with any companies that are relevant to this study.
Also, most of the residents had significant experience as part There are no conflicts of interest or sources of funding to declare.
of resuscitation teams (Table 1). As a result, there may have
been less of a difference in performance between the two Copyright: © 2024 Raper et al. This is an open access article
distributed in accordance with the terms of the Creative Commons
groups. Our study found RCDP was well received by our
Attribution (CC BY 4.0) License. See: http://creativecommons.org/
learners, but the data is limited by learner evaluation at licenses/by/4.0/
Kirkpatrick levels I and II. While we believe learner
perceptions in instruction are important for engagement,
future investigations should focus on objective REFERENCES
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