# Non-technical skill performance during remote, international, augmented-reality neonatal resuscitation protocol simulations: a feasibility study

## TL;DR

This study shows that remote, international AR simulations can effectively assess non-technical skills during neonatal resuscitation training.

## Contribution

The study demonstrates the feasibility of using AR for remote, international neonatal resuscitation training and NTS assessment.

## Key findings

- Participants showed adequate non-technical skills with ANTS scores of 2.5–2.9 and BARS scores of 5.2–5.4.
- System usability was high, and ergonomic results indicated minimal physical or cognitive burden.
- NTS performance in AR simulations was comparable to traditional in-person simulations.

## Abstract

Neonatal resuscitation requires mastery of technical and non-technical skills (NTS). The Neonatal Resuscitation Program (NRP) emphasizes ventilation, along with effective leadership, teamwork, and situational awareness. Simulation-based education is central to NTS training but is resource-intensive with limited access in low- and middle-income countries. Augmented reality (AR) medical simulations offer a scalable, remote solution with fewer logistical barriers.

We conducted a prospective, single-arm feasibility study evaluating a remote AR medical simulation for assessing NTS during neonatal resuscitation. Instructors based in Northern California (Stanford School of Medicine) remotely facilitated pediatric and anesthesiology residents in Santiago, Chile (University of Chile) as team leaders in an NRP scenario delivered using an AR medical simulator. The primary outcome was NTS performance measured with the Anesthetists’ Non-Technical Skills (ANTS) tool. Secondary outcomes included the Behaviorally Anchored Rating Scale (BARS), system usability via the System Usability Scale (SUS), and ergonomics via the ISO 9241 − 400 scale.

Thirty-four residents completed all sessions. Participants demonstrated adequate NTS performance, with ANTS scores 2.5–2.9 (scale 1–4) and BARS scores 5.2–5.4 (scale 1–9), similar to those observed in traditional, in-person simulations. SUS responses indicated high usability, and ergonomic results suggested minimal physical or cognitive burden.

This feasibility study shows that participants demonstrated measurable NTS performance during remote, international AR neonatal resuscitation simulations, as assessed using ANTS and BARS.

The online version contains supplementary material available at 10.1186/s12909-026-08611-2.