Improving Accuracy in Cardiopulmonary Resuscitation Training: Results on Undergraduate Nursing School Students’ with OMNI2 Simulator

Round 1

Reviewer 1 Report (Previous Reviewer 1)

Comments and Suggestions for Authors

The authors have addressed all my comments sufficiently.

Author Response

Thank you for your thoughtful review and valuable feedback, which have greatly improved the quality of this article.

Reviewer 2 Report (New Reviewer)

Comments and Suggestions for Authors

The authors address an interesting topic, but they need to improve the following issues:
-There is a serious problem with citations in the format specified by the journal. Full stops cannot come before the reference [1] but must come after it, as in a normal sentence, otherwise it is incorrect. This and other errors in the guidelines must be revised throughout the article.

-The introduction is very brief and lacks further information and relevant references. In particular, more information is needed about nursing students and the teaching they provide in order to justify the reasons for the study.

-The methodology of the study is unclear. Qualitative? Quantitative? Why? Nothing is stated at the beginning of the section.

-The presentation of results could be clearer. It is recommended that authors not only provide data, but also explain what each piece of data means, otherwise it is difficult for the reader to understand.

-- The discussion needs improvement. There is not a single reference in the first few paragraphs. The authors need to differentiate between results and discussion. If it is discussion, it needs to be discussed with the authors, and this has not been done.

--In the other sections of the discussion, there are practically no references to authors, only three, which is too few for a discussion section in a journal.

-The conclusions are also expandable; limitations and future lines of research could be added.

Be careful with the colours underlining the document.

Author Response

Comment 1: There is a serious problem with citations in the format specified by the journal. Full stops cannot come before the reference [1] but must come after it, as in a normal sentence, otherwise it is incorrect. This and other errors in the guidelines must be revised throughout the article.

Response 1: Than you for your comment. Citations have been corrected and modified according to the journal's guidelines.

Comment 2: The introduction is very brief and lacks further information and relevant references. In particular, more information is needed about nursing students and the teaching they provide in order to justify the reasons for the study.

Response 2: Your input is greately appreciated. For this reason, we included a paragraph on nursing teaching curricula and the importance of CPR / BLS training. You may find it in the revised manuscript: page 2, lines 50-63 

Comment 3: The methodology of the study is unclear. Qualitative? Quantitative? Why? Nothing is stated at the beginning of the section.

Response 3: Our study followed a quantitative methodology, as it relied exclusively on objective numerical data generated by the OMNI2 simulator, applied statistical analyses to evaluate performance metrics against preset ERC targets, and collected no qualitative data such as interviews or open-ended responses

Comment 4: The presentation of results could be clearer. It is recommended that authors not only provide data, but also explain what each piece of data means, otherwise it is difficult for the reader to understand.

Response 4: Thank you for this helpful observation. We agree that presenting results with clearer explanation enhances readability and interpretation. In response, we have revised the Results section to not only report the numerical findings but also explain their meaning and relevance. Specifically, we now clarify what each metric represents (e.g., why exceeding session time is significant, how deviations in compression depth affect CPR quality, and the implications of ventilation performance). These additions aim to guide the reader through the results and improve overall understanding. You may find the corrected results section in the revised manuscript on page 5, lines 180-181, 186-190, 200-204, 206-222 and page 6, lines 224-227.

Comments 5&6: The discussion needs improvement. There is not a single reference in the first few paragraphs. The authors need to differentiate between results and discussion. If it is discussion, it needs to be discussed with the authors, and this has not been done. n the other sections of the discussion, there are practically no references to authors, only three, which is too few for a discussion section in a journal.

Response 5&6: Thank you for your valuable comments. To support the findings of our study, we included more references based on already existing guidelines. You may find the corrected version, in the revised manus6cript on page 6, lines 240-244, 246-250, page 7, lines 261-288, 298-301, page 8, lines 302-309, 320-327, 338-350

Comment 7:The conclusions are also expandable; limitations and future lines of research could be added.

Response 7: Thank you for your comment. We included a paragraph above conclusions with limitations and future research information. You may find them in the revised manuscript on page 10, lines 414-421. 

Reviewer 3 Report (New Reviewer)

Comments and Suggestions for Authors

This paper presents an analysis of the use of the OMNI2 simulator with 144 undergraduate nursing students.
Although the 8-hour BLS seminar is not without importance, it does not deviate from the standard seminar format commonly implemented in nursing education; therefore, the seminar itself does not appear to carry strong academic value.
Moreover, the study does not represent a full or optimized utilization of the OMNI2 simulator, which limits its scholarly contribution.

There are various possible ways to employ such a simulator, yet the authors have not articulated why they chose the current approach or how it compares with alternative modes of use.
At present, the paper merely demonstrates one simple method of application.
It would be valuable to present and compare different modes of simulator utilization, identifying which approaches are pedagogically or technically most meaningful.

Specific Comments

1. Table 2 simply reports measurement outcomes; no modeling or deeper analysis appears to have been conducted.

2. The knowledge assessment test uses the same question set for both the pre- and post-test, making improvement inevitable.
It would be more logical to employ different question sets to avoid practice effects.

3. There is no retest or follow-up measurement using the OMNI2 simulator.
To quantify improvement, participants should have performed CPR again after feedback to evaluate measurable gains.

4. The paper lacks a modeling perspective, focusing only on a direct interpretation of OMNI2 measurements without analytical depth.

5. Are there no alternative simulators besides OMNI2?
A brief comparison of possible simulator options and a justification for selecting OMNI2 would strengthen the study’s rationale.

6. The title claims “Improving Accuracy,” but the study merely evaluates and analyzes performance; it does not actually demonstrate improvement.
This inconsistency weakens the logical coherence and scholarly rigor of the paper.

7. Even a small-scale or single-subject follow-up experiment could have been added to demonstrate improvement in accuracy.
In its current form, the manuscript’s argumentation and experimental evidence seem insufficient for publication.

Author Response

Comment 1: Table 2 simply reports measurement outcomes; no modeling or deeper analysis appears to have been conducted.

Response 1: Thank you for this observation. Table 2 was intended to provide a clear summary of the measurement outcomes as a foundational reference for the subsequent analyses presented in the manuscript. While no modeling was conducted in this table itself, these results inform and support the modeling and deeper analysis discussed later. 

Comment 2: The knowledge assessment test uses the same question set for both the pre- and post-test, making improvement inevitable. It would be more logical to employ different question sets to avoid practice effects.

Response 2: Thank you for this valuable comment. The purpose of the pre-test was to assess the baseline knowledge of participants, as they had not received prior official BLS training. We intentionally used the same question set for the post-test to measure the immediate impact of the intervention (seminar) on the same knowledge items, allowing for a direct comparison of improvement. This approach also ensures that changes in scores reflect learning gains on the specific critical concepts covered, rather than variability introduced by differing question sets. We have clarified this rationale in the manuscript.

Comment 3: There is no retest or follow-up measurement using the OMNI2 simulator. To quantify improvement, participants should have performed CPR again after feedback to evaluate measurable gains.

Response 3: We aknowlegde that this is indeed one of the limitations of our study. Upon the completion of this study, we aim to design a new one (6 months and 1 year follow-up) to assess retention of theoretical knowledge and practical skills.

Comment 4: The paper lacks a modeling perspective, focusing only on a direct interpretation of OMNI2 measurements without analytical depth.

Response 4: The primary aim of our observational study was to present and interpret the OMNI2 measurement outcomes directly and objectively, as these provide important practical insights in the context of BLS training. While we did not perform additional modeling in this manuscript, the reported measurements form a foundation for future analytical work and more complex modeling, potentially showing new pathways to improve training and skill acquisition.

Comment 5: Are there no alternative simulators besides OMNI2?A brief comparison of possible simulator options and a justification for selecting OMNI2 would strengthen the study’s rationale.

Response 5: Thank you for your feedback. Not that we are aware of, neither that has been released in the market of the country that our study was conducted. 

Comment 6: The title claims “Improving Accuracy,” but the study merely evaluates and analyzes performance; it does not actually demonstrate improvement. This inconsistency weakens the logical coherence and scholarly rigor of the paper.

Response 6: Thank you for this insightful comment. The title is intended to emphasize the potential of leveraging technology to improve accuracy and skill acquisition in BLS training. While the study primarily evaluates and analyzes performance, it demonstrates how simulation-based assessment—considered the gold standard for skill acquisition—can objectively identify gaps between perceived and actual performance. Such objective measurements can inform and refine teaching methods, ultimately contributing to improved accuracy in future training. We have clarified this rationale in the manuscript to better align the title with the study’s objectives.

Response 7: Even a small-scale or single-subject follow-up experiment could have been added to demonstrate improvement in accuracy. In its current form, the manuscript’s argumentation and experimental evidence seem insufficient for publication.

Comment 7: We thank the reviewer for this suggestion. Our study was designed as an initial evaluation to establish baseline performance and assess the feasibility of using objective measurement tools in BLS training. While a follow-up experiment demonstrating improvement would indeed be valuable, the primary goal here was to characterize performance and highlight discrepancies between perceived and objectively measured skills. These findings provide essential groundwork for future intervention studies that could directly measure improvement. We have added a "Limitations and future research" paragraph in the manuscript to clarify this scope and the rationale for the current study design.

Round 2

Reviewer 2 Report (New Reviewer)

Comments and Suggestions for Authors

Dear authors, thank you for improving the article.

Reviewer 3 Report (New Reviewer)

Comments and Suggestions for Authors

After reading the authors’ responses, I realized that although the experiments are somewhat limited, this in itself can be reasonably framed as future work. I also feel that the depth of the Discussion section adequately reflects the core themes and contributions of the paper.

Although it is uncommon to change a decision from reject to accept at this stage, I intend to revise my recommendation to accept, leaving the final judgment to the editor.

This manuscript is a resubmission of an earlier submission. The following is a list of the peer review reports and author responses from that submission.

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The manuscript titled "Improving Accuracy in Cardiopulmonary Resuscitation Training: Results on Undergraduate Nursing School Students with OMNI2 Simulator" investigates the impact of using the OMNI2 Simulator to enhance the accuracy of cardiopulmonary resuscitation (CPR) training among undergraduate nursing students. The study involved participants who provided written informed consent and filled out a first-aid questionnaire before and after the seminar. The research analyzed demographic characteristics and assessed the effectiveness of the training program through statistical analysis using SPSS software. The study found significant improvements in CPR accuracy among the participants, indicating the potential of modern simulation technology in medical education.

The problem considered is interesting and important, and the findings are likely to be interesting to others working in this field. I encourage the authors to consider the following comments to strengthen the manuscript (in the order of importance):

1. The statistical analysis section mentions the use of a paired t-test but does not provide enough information on the data collection process or the rationale for choosing this test. I suggest the authors elaborate on the data collection methods, including how the data were recorded and any potential biases. Additionally, explain why the paired t-test was chosen over other statistical methods and discuss any assumptions made.
2. Following the previous comment, the methodology section also lacks detail on the specific training program and the structure of the seminar. The authors should consider providing a comprehensive description of the training program, including the duration, content, and any instructional methods used. This will help readers understand the context of the training and its potential impact on the results.
3. The results section briefly mentions the demographic findings but does not fully explore their implications on the training outcomes. I suggest the authors consider discussing the demographic characteristics in more detail and analyzing how factors such as age, gender, and familiarity with technology might have influenced the training results.
4. While the introduction provides a brief overview of the importance of CPR training and the use of simulation technology, it would benefit from a more detailed literature review to contextualize the significance of the OMNI2 Simulator within existing research. It would help highlight the novelty and relevance of this study.

Considering the above-mentioned comments, I suggest a major revision.

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors This manuscript demonstrate Clarity of scope, logical presentation and discussion of ideas. I am confidant that this article will have accessibility to a wide audience, including readers who are not specialists in the field. Also a fair and accurate discussion of the literature Clarity and accuracy of display items. All references are appropriate, well-curated, up-to-date and fit the scope of the article. Comments on the Quality of English Language This manuscript demonstrate Clarity of scope, logical presentation and discussion of ideas. I am confidant that this article will have accessibility to a wide audience, including readers who are not specialists in the field. Also a fair and accurate discussion of the literature
Clarity and accuracy of display items. All references are appropriate, well-curated, up-to-date and fit the scope of the article.

Author Response

Dear Reviewer, 

Thank you for your comments and kind words. 

I have no further modifications to my manuscript. 

Thank you in advance for your collaboration. 

Reviewer 3 Report

Comments and Suggestions for Authors

In this manuscript, the authors aimed to evaluate the accuracy of the OMNI2 simulator in CPR training for undergraduate nursing school students.

The main idea of the research is relevant and addresses an important topic in medical education. However, the study contains several serious flaws in research methodology and study design that significantly impact the quality of the work and applicability of the findings.

Major comment

The main issue of the study relates to the study design and subsequent statistical analysis. The choice to use a paired t-test to compare data from actual CPR performances to predefined target values seems inappropriate. Any statistical hypothesis test (such as the t-test) has certain assumptions that need to be met in order for the test results to be meaningful. In particular, for the t-test, the groups being compared need to be representative samples from the target populations, the data points within the sample should be independent of each other, and the data being analyzed needs to be normally distributed. Neither of these assumptions are true for the reference values to which each student’s performance is being compared, because the reference values are always the same. In addition, the paired t-test should be used when the data points between the two sample being compared are somehow mutually dependent (e.g. if the same student conducted the same exercise twice, but a month apart, then the results of the same student for the first and second exercises could be compared with a paired t-test). In this study, there is no reason to assume that actual performance parameters and reference target values would be dependent data points.

This lead to a larger issue related to the study design. The aim of the study was to evaluate the  accuracy of the OMNI2 simulator in CPR training (lines 74 – 75), however, what seems to actually have been done was to evaluate the students’ performance of CPR using the OMNI2 simulator. These are two completely different things, and it is impossible to use the data obtained in this study to evaluate the accuracy of the simulator. To the contrary, the authors seem to use the simulator as a reference point for the evaluation of the students’ performance, indicating that the OMNI2 simulator was considered accurate (or sufficiently accurate) in the context of the study design.

Regardless whether this discrepancy between the study aim and study design is merely due to imprecise wording or not, the study design itself still suffers from a rather serious flaw in the sense that it is not possible to test a scientific hypothesis with the current design. Namely, comparing students’ performance to a set of predetermined values is commonplace in education and is usually part of any type of assessment (most people would call this an exam). The only conclusion one can draw from the data provided is whether, on average, students met the required target values (i.e. assessment criteria) or not. In order to determine the strengths and limitations of simulation-based learning and its impact on patient outcomes (as the authors claim to have done, lines 75 – 77), much additional research is needed. The data presented in the study do not reveal, for example, why students, on average, performed 37 compressions per cycle instead of 30 and no real effect on patient outcome can be inferred from this data point. Furthermore, from a single evaluation session, it is impossible to determine what the long-term impact of simulation-based training on the students’ performance was and what recommendations to make in order to improve the outcome of such training. Multiple sessions during a much longer time period would be necessary to evaluate this properly.

 

Minor comments

1) The sentence “Global statistics highlight…” (lines 40 – 42) seems to be missing some context. What does it mean that “a bystander with CPR skills has a mean value of 58%”?

2) In lines 47 – 49, it might be more relevant to refer to BLS guidelines, since the students seem to be practicing BLS scenarios, rather than ALS.

3) Line 74: instead of “CPR training”, it would perhaps be better to specify that this refers to BLS training in particular.

4) Lines 91 – 93: from the rest of the text, I believe the authors are referring to a written test (like some kind of formative exam or quiz, i.e. a type of assessment), rather than a “questionnaire”, which is usually used to refer to a survey or opinion poll.

5) Table 1: Some of the findings regarding the performance parameters need more context for the reader to be able to meaningfully interpret them. For example, how is it possible that students performed, on average, only 1.71 cycles, even though the authors state in lines 138 and 139 that the students were supposed to perform two sequential CPR cycles? From the fact that the students’ session lasted on average 15 seconds above the target 60 seconds, it doesn’t seem that there was a time limit imposed on the students, which would otherwise explain why some students didn’t finish the two full cycles. In addition, the interpretation of the parameter “full recoil” is not clear. Intuitively, it would make sense for the simulator to measure in which percentage of compressions a full recoil was achieved. However, based on the text in lines 142 – 144, it is worded as if the 90.9% value refers to the percentage of students that achieved full recoil during the session, which is a completely different things. Finally, some target values differ between Table 1 and the text (e.g. target compression depth in Table 1 was 5.7 cm and in the text, line 143 it is stated as 6 cm).

6) Lines 127 – 128:  What is the significance of this statement in the context of the study? Why is it important that participants owned a computer and a smartphone? I image it is due to the fact that the participants had to use a device with a touch screen to operate the simulator, but this is stated nowhere in the text. In addition, is owning a computer really related to the ability to operate a medical simulator? Finally, if this data is relevant to the performance outcomes, the authors need to provide exact values and show correlation (or lack thereof) with performance outcomes.

7) Lines 131 – 132: There seems to have been some survey conducted pertaining to the participants’ background. If so, the survey items need to be shown in the manuscript (at least as supplementary material), the authors need to describe how the questionnaire was validated (if it is not a pre-existing validated questionnaire), how it was administered, how anonymity was preserved, what was the response rate, how was non-response bias evaluated, etc.

8) Lines 135 – 137: It is unclear what these test results have to do with the purpose of the study. This seem to be more informative on the outcome of the theoretical portion of the training program. If the authors wish for this to be more informative, they should give more information on the scores achieved in the pre- and post-tests, as well as explicitly state whether the pre- and post-test contained the same questions or just similar questions.

9) The Results section has only one subheading (Demographic findings), even though only the first paragraph seems to be related to that subheading.

10) Lines 172 – 181: In order to be able to interpret the performance pertaining to ventilation, the authors need to describe how students were expected to perform ventilation in this scenario. Was it mouth-to-mouth rescue breaths or could they use some type of aid (e.g. mask ventilation)? In general, it would be useful to state which part of the BLS algorithm (according to the ERC 2021 guidelines?) was being practiced in this training scenario.

11) Lines 189 – 191: This section needs to be expanded significantly. Comparing the study’s findings to existing research is a key part of the discussion.

12) Lines 200 – 201: The authors state that: “OMNI2 simulator implementation, as also supported by our study, offers unparalleled advantages in CPR education”. It is unclear how this was demonstrated in this manuscript, since in almost all of the analyzed parameters the students did not meet target values. The authors probably meant to state that this type of simulation can offer valuable feedback to trainees during training sessions.

13) Ethical approval for the study is not mentioned. The number of the ethical approval and the institution that issued it need to be stated, as well as all relevant statements pertaining to it (e.g. how was informed consent obtained from the participants, etc.).

Comments on the Quality of English Language

Some language improvements would be benefitial to improve the overall quality of the text. I noted some inconsistencies in phrasing in the minor comments.

Author Response

Please see the attachment.

Author Response File: Author Response.pdf