Letter to the editor concerning ‘can implementation of in situ simulation support rural emergency provider self-confidence and improve patient safety? A mixed-methods study’

Dear Editor, We read with interest the mixed-methods study by Diebel et al., which evaluates the implementation of in situ simulation in a rural Canadian Emergency Department (Espanola Regional Hospital and Health Centre) with an aim to enhance provider self-confidence and identify latent safety threats. 1 The use of a validated satisfaction and confidence scale, alongside thematic analysis of debriefing responses, represents a structured and commendable approach to evaluating simulation effectiveness in a rural, resource-constrained context. However, certain design and interpretive elements warrant closer examination. The study administered only post-intervention surveys, precluding meaningful measurement of change. Without a pre-simulation baseline, it is unclear whether the high self-confidence scores reflect actual learning gains or pre-existing attitudes among providers. Clinically, this distinction is critical, as interventions intended to improve preparedness must demonstrate measurable change rather than static self-perception. 2 Inclusion of pre–post paired evaluations, even with brief or adapted instruments, would strengthen causal inferences about the intervention’s educational impact. The convenience sampling strategy, while pragmatic, may introduce hidden skew in staff representation.3 Participants were those on duty or available during quieter clinical periods, potentially excluding less confident or higher-risk clinicians from the sample. This sampling pattern risks overestimating the true generalisability of simulation-induced confidence or engagement. 4 Given the small provider base typical of rural emergency departments, representativeness is essential to ensure that institutional training reflects the full range of competencies and needs. The identification of latent safety threats, such as equipment positioning and gaps in paediatric resuscitation readiness, is a valuable outcome. However, the absence of formal triangulation, such as observational validation or adverse event tracking, limits the ability to distinguish between perceived and actual safety vulnerabilities. 5 For instance, the placement of video laryngoscope power cords was highlighted in simulations but not linked to documented clinical hazards. Bridging simulation insights with real-world incident reports or root-cause analyses may enhance the fidelity of these findings and inform more actionable quality improvement. We commend the authors for addressing an urgent gap in rural emergency training by demonstrating the feasibility of in situ simulation using existing infrastructure. Their structured debriefings, theme-driven analysis and follow-up implementation steps, including ventilator training and procurement of paediatric equipment, provide a replicable model for rural departments across Canada and beyond. Future studies may benefit from longitudinal outcome tracking, control comparisons and the integration of objective clinical metrics to substantiate the impact of simulation-based education on rural patient care and provider performance. Financial support and sponsorship: Nil. Conflicts of interest: There are no conflicts of interest. Response Dear Editor, We are grateful to the correspondents for reading our paper and for their thoughtful engagement with our design and interpretation. Their comments help strengthen an emerging rural simulation literature. Pre–post measurement: We agree that paired pre–post evaluations better quantify change. As noted in our limitations, we used post-only surveys to limit burden on a small workforce during live clinical hours. An ultra-brief pre-survey might have been possible, though likely unvalidated. With the programme now established and staff comfort is higher, we plan to implement concise digital pre–post measures (e.g., five-item scales via bedside QR codes) to capture paired change with minimal disruption. Sampling and representativeness: The potential for bias with convenience sampling is acknowledged in our limitations. In a one-physician/one-nurse overnight model, shift randomisation risks unsafe understaffing. To broaden representation, we will rotate sessions across shifts and invite targeted participants based on needs assessments, including clinicians who self-identify as less confident. Although the absolute numbers were small, participants represented the majority of our ED nursing workforce. Scheduling simulations during quieter periods with maximal staffing provided the widest feasible reach. Triangulating latent safety threats (LSTs): We agree that linking simulation-identified LSTs to operational data can distinguish perceived from actual hazards. As an early-phase project, our aim was to surface issues rapidly and feed them to leadership for action. Going forward, we will align LSTs with existing quality structures such as incident reports and equipment check logs. For items such as video-laryngoscope cord placement, we will add observational checks during mock codes and simulations and audit the effects of equipment relocations (e.g., cord-related delays, bed-movement constraints and tripping hazards) to ensure changes translate into safer practice. Balancing rigor and feasibility in rural settings: We share the correspondents’ desire for stronger causal inference and objective outcomes. We also note that in underserviced contexts without research staff, a ‘perfect-or-nothing’ threshold can stall practical improvements. Our approach was to start small, use validated tools, disclose limitations and convert findings into changes (paediatric NIPPV masks, ventilator refreshers and PPE re-layout). With the platform now accepted by staff, we are positioned to add rigour: brief paired measures, longitudinal follow-up, and – where volumes permit – comparators across similar rural sites. In sum, we appreciate the constructive critique. It affirms the value of rural ISS while pointing to concrete next steps that we are already incorporating. We hope our experience encourages other small centres to begin, learn and iteratively strengthen methods as capacity grows. Sincerely, Aidan Wharton, MD CCFP (EM), Northern Ontario School of Medicine University on behalf of all authors.