Enhancing Pediatric Residency Training Through Peer-Education Based Gamified Simulation

The increasing number of Italian pediatric residency contracts over the past five years has raised concerns about its impact on clinical training opportunities, particularly in high-demand subspecialties such as Emergency Rooms (ER) and NICU/PICU departments.¹ These rotations are fundamental for equipping future healthcare professionals with a comprehensive clinical foundation,^1,2

Recent changes in how residents are anticipatedly integrated into primary and secondary hospitals, with recruitments within the public healthcare system before the regular completion of the 5-year residency course, have further highlighted the pressing need for a standardized system to assess residents’ autonomy,³.⁴ Similar trends have been observed at the University of Genoa, a tertiary-level academic children’s hospital in northern Italy. Despite ranking in the top quartile for annual residency contracts, our program has experienced a notable decline in pediatric ER rotations over the past four years. Specifically, daytime rotation hours have decreased by 29%, while nighttime rotations have been reduced by 60%, reflecting significant adjustments in clinical training exposure (Figure 1).

Figure 1 Changes in Pediatric ER Rotation Hours at the University of Genoa (2019 vs 2023). Notes: Significant reduction in daytime and nighttime work shifts and hours for pediatric residents over the four-year period, reflecting the adjustments in clinical training exposure reported at the University of Genoa Pediatric Residency Program.

Simulation-based curricula offer a promising strategy to maximize residents’ exposure to high-stakes situations requiring significant technical, cognitive, and emotional skills. Such curricula could help bridge the gaps identified above. Engaging residents in simulation programs through competitions supports their progression toward greater autonomy in the final stages of training.⁵

Simulation is pivotal in modern medical education, focusing on cognitive knowledge, critical thinking, psychomotor skills, and clinical performance.⁶ In pediatric training, simulation-based education is particularly valuable, enhancing learners’ confidence and performance, especially in emergency and neonatal care. These areas benefit from simulation because it allows for deliberate practice in rare but high-stakes scenarios.⁷ As simulation becomes increasingly integrated into pediatric education, it is essential to develop structured curricula and train instructors to ensure the effectiveness and transferability of the skills and knowledge.⁸

A 2019 nationwide survey covering 71% of Italian pediatric residency programs revealed that 88% of respondents had received fewer than five hours of simulation-based training in the previous year, with 66% having participated in no simulation activities. Consequently, 93% expressed interest in participating in simulation-based training to enhance their decision-making abilities in complex medical situations and improve both technical and non-technical skills.⁹

Simulation-based competitions, such as the “Pediatric Simulation Games” and the “Neonatal Simulation Competition” held annually in Italy, are excellent examples of gamified training methods that develop both technical and non-technical skills among pediatric residents.¹⁰ Gamification, defined as the integration of game-design elements into non-game contexts, has emerged as a powerful tool in healthcare education. By incorporating interactive elements such as points, badges, and leaderboards, gamification increases engagement, promotes active participation, and provides immediate feedback, thus supporting skill acquisition and self-directed learning.¹¹

Gamified training transforms the learning environment, making it more dynamic and interactive. It helps residents acquire complex skills, such as managing pediatric emergencies, in a more effective and enjoyable manner. Participants are more emotionally and mentally invested, retaining information better, improving teamwork and communication, and performing more effectively under pressure. The combination of increased engagement, motivation, and practical application leads to superior learning outcomes, making the training more impactful if correctly applied by educators.¹²

Studies examining the first American simulation-based gamified protocol designed for ER in-training doctors, “SimWars” have shown a statistically significant improvement in In-Training Examination (ITE) scores for scenarios involving Abdominal/Gastrointestinal, Thoracic, OBGyn, and Trauma.¹³ A similar positive effect has been observed in the Italian initiative “SIMCUP Italia”, where residents’ self-confidence was significantly improved immediately following the competition.¹⁴ These initiatives also emphasize non-technical skills, such as communication, teamwork, and decision-making, which have become increasingly important in recent years for reducing human errors in healthcare settings, particularly in the management of emergency and complex situations.¹⁵

To prepare residents for such competitions, we developed a pilot peer-education training program for our institution’s fourth- and fifth-year residents. This program focused on specific Pediatric Advanced Life Support (PALS) and Neonatal Life Support (NLS) scenarios. It included supplementary non-formal education activities to enhance team building, leadership, cooperation, and communication skills. The training sessions were led by residents who had previously participated in these competitions under the guidance of expert tutors.

Building on this pilot experience, following the standards required by the Italian Ministry of University on the residency program standards¹⁶ we have developed a comprehensive training curriculum for residents that begins in their first year. This curriculum gradually builds both technical and non-technical competencies through a structured progression of simulation-based learning activities. The proposed program, outlined in Table 1, follows a structured progression from foundational skill labs in the first year (practical workshops, relational simulations, and flipped activities focused on non-technical skills such as teamwork, communication, and decision-making), to advanced, high-fidelity simulations in the later years. To enhance motivation and engagement, gamification elements are also integrated throughout the curriculum, including the use of open badge systems for progressive tracking and recognition of achievements.¹⁷ Residents earn badges for mastering specific skills, completing scenarios, and demonstrating leadership in complex simulations. These badges serve as verifiable credentials and can be shared on professional platforms. Additionally, rewards such as access to advanced workshops, competitive event participation, and milestone recognition encourage active participation and progression. In order to provide a future standardization of the evaluation progress, we propose the integration of validated international assessments systems together with the informal ones.¹⁸

Table 1 Comprehensive Training Program with Gamification System

The gamified curriculum is structured to align with the residents’ academic progression, with each year introducing more complex scenarios that match their skill level. Faculty members oversee the program, ensuring the training meets educational standards and providing feedback during debriefing sessions.

A key feature of this curriculum is the use of experienced residents as peer tutors under faculty supervision, which not only makes learning more relatable and accessible but also enhances training efficiency. Since residents have more flexible schedules than senior faculty, we can increase the frequency and adaptability of training sessions, ensuring that learning opportunities are more widely available.¹⁹ The peer-led model thus enriches the learning experience while optimizing training time, fostering well-rounded development of essential pediatric competencies. Moreover, simulators with progressively increasing levels of fidelity allow learners to gradually build their clinical competence.²⁰ This approach starts with mastering basic procedures and algorithms applied in increasing complexity scenarios. This progression reinforces technical skills and provides the opportunity to develop and refine non-technical skills and crisis resource management, ensuring a comprehensive and integrated approach to clinical training.¹⁵

To further explore the advantages and challenges of integrating gamification into pediatric residency training, we highlight the need for adequate resources, faculty training, and alignment with curricular goals. While extending case study learning hours is essential, faculty and staff involvement is crucial to ensure the curriculum’s integration with the overall educational framework.

In the end, this manuscript is aimed to present the educational framework of our proposal. We acknowledge that future studies incorporating pre-post assessments would be valuable in evaluating the effectiveness of this gamified simulation approach and its impact on residents’ skills. In this direction, researchers should also consider incorporating students’ perspectives on the effectiveness of this approach, gathering feedback on their experiences and accomplishments.