{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T01:18:28Z","timestamp":1760059108348,"version":"build-2065373602"},"reference-count":38,"publisher":"MDPI AG","issue":"2","license":[{"start":{"date-parts":[[2025,5,20]],"date-time":"2025-05-20T00:00:00Z","timestamp":1747699200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Eunice Kennedy Shriver National Institute of Child Health &amp; Human Development of the National Institutes of Health","award":["R01HD091179"],"award-info":[{"award-number":["R01HD091179"]}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Virtual Worlds"],"abstract":"<jats:p>Neonatal endotracheal intubation (ETI) is a complex medical procedure that demands extensive training before practicing on real patients. Clinical studies indicate that the conventional training approach, typically conducted in idealized conditions with task trainers, has a low skill transferability rate compared to performance in the dynamic environments common in intensive care units (ICUs). According to cognitive load theory, novices encounter difficulties in multitasking scenarios, exhibiting performance declines due to competition among tasks for cognitive resources; experts, having achieved automaticity, have more cognitive resources to handle additional tasks present in high-stress environments and therefore exhibit less performance degradation. Current ETI skill assessment methods do not capture these differences in expertise. To bridge this gap, we develop an innovative dual-task mixed-reality (MR) simulator to evaluate the influence of cognitive distractors on ETI and substantiate effective performance measurement metrics. Results affirm that experts demonstrate superior proficiency in handling extraneous cognitive loads compared to novices. This has important implications for understanding how to measure novice performance in ETI settings. Taken together, the dual-task ETI training simulator and the associated automated skill evaluation metric system hold promise for enhancing training in neonatal ETI practice and ultimately leading to improved patient care outcomes.<\/jats:p>","DOI":"10.3390\/virtualworlds4020020","type":"journal-article","created":{"date-parts":[[2025,5,20]],"date-time":"2025-05-20T08:41:12Z","timestamp":1747730472000},"page":"20","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Effect of Cognitive Distractors on Neonatal Endotracheal Intubation Performance: Insights from a Dual-Task Simulator"],"prefix":"10.3390","volume":"4","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-3545-0354","authenticated-orcid":false,"given":"Yan","family":"Meng","sequence":"first","affiliation":[{"name":"Department of Computer Science, George Washington University, Washington, DC 20052, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Shang","family":"Zhao","sequence":"additional","affiliation":[{"name":"Institute for Advanced Research, University of Science and Technology of China, Suzhou 215123, China"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7272-1523","authenticated-orcid":false,"given":"Xiaoke","family":"Zhang","sequence":"additional","affiliation":[{"name":"Department of Statistics, George Washington University, Washington, DC 20052, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"John","family":"Philbeck","sequence":"additional","affiliation":[{"name":"Department of Psychological & Brain Sciences, George Washington University, Washington, DC 20052, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2277-1538","authenticated-orcid":false,"given":"Prachi","family":"Mahableshwarkar","sequence":"additional","affiliation":[{"name":"Department of Psychological & Brain Sciences, George Washington University, Washington, DC 20052, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Boyuan","family":"Feng","sequence":"additional","affiliation":[{"name":"Department of Computer Science, George Washington University, Washington, DC 20052, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Lamia","family":"Soghier","sequence":"additional","affiliation":[{"name":"Department of Neonatology, Children\u2019s National Hospital, Washington, DC 20010, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"James","family":"Hahn","sequence":"additional","affiliation":[{"name":"Department of Computer Science, George Washington University, Washington, DC 20052, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2025,5,20]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","unstructured":"Weiner, G.M., and Zaichkin, J. (2021). Textbook of Neonatal Resuscitation, American Academy of Pediatrics and American Heart Association. [8th ed.].","DOI":"10.1542\/9781610025256"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"e1229","DOI":"10.1542\/peds.2014-3700","article-title":"Predicting neonatal intubation competency in trainees","volume":"135","author":"DeMeo","year":"2015","journal-title":"Pediatrics"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"e2020036145","DOI":"10.1542\/peds.2020-036145","article-title":"Intubation competence during neonatal fellowship training","volume":"148","author":"Evans","year":"2021","journal-title":"Pediatrics"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"635","DOI":"10.1213\/00000539-199803000-00037","article-title":"Learning manual skills in anesthesiology: Is there a recommended number of cases for anesthetic procedures?","volume":"86","author":"Konrad","year":"1998","journal-title":"Anesth. Analg."},{"key":"ref_5","doi-asserted-by":"crossref","unstructured":"Xiao, X., Zhao, S., Meng, Y., Soghier, L., Zhang, X., and Hahn, J. (2020, January 22\u201326). A physics-based virtual reality simulation framework for neonatal endotracheal intubation. Proceedings of the 2020 IEEE Conference on Virtual Reality and 3D User Interfaces (VR), Atlanta, GA, USA.","DOI":"10.1109\/VR46266.2020.00077"},{"key":"ref_6","doi-asserted-by":"crossref","unstructured":"Meng, Y., and Hahn, J.K. (2023, January 15\u201318). An Automatic Grading System for Neonatal Endotracheal Intubation with Multi-Task Convolutional Neural Network. Proceedings of the 2023 IEEE EMBS International Conference on Biomedical and Health Informatics (BHI), Pittsburgh, PA, USA.","DOI":"10.1109\/BHI58575.2023.10313510"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"1359","DOI":"10.1016\/j.resuscitation.2013.03.014","article-title":"Neonatal intubation performance: Room for improvement in tertiary neonatal intensive care units","volume":"84","author":"Haubner","year":"2013","journal-title":"Resuscitation"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1037\/0033-295X.84.1.1","article-title":"Controlled and automatic human information processing: I. Detection, search, and attention","volume":"84","author":"Schneider","year":"1977","journal-title":"Psychol. Rev."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"257","DOI":"10.1207\/s15516709cog1202_4","article-title":"Cognitive load during problem solving: Effects on learning","volume":"12","author":"Sweller","year":"1988","journal-title":"Cogn. Sci."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"583","DOI":"10.1177\/001872088803000504","article-title":"Automaticity, resources, and memory: Theoretical controversies and practical implications","volume":"30","author":"Logan","year":"1988","journal-title":"Hum. Factors"},{"key":"ref_11","doi-asserted-by":"crossref","unstructured":"Wickens, C.D. (2020). Processing resources and attention. Multiple Task Performance, CRC Press.","DOI":"10.1201\/9781003069447-2"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"502","DOI":"10.1016\/j.amjsurg.2006.11.010","article-title":"Redefining simulator proficiency using automaticity theory","volume":"193","author":"Stefanidis","year":"2007","journal-title":"Am. J. Surg."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"804","DOI":"10.1016\/j.amjsurg.2009.04.027","article-title":"Distractions and surgical proficiency: An educational perspective","volume":"198","author":"Szafranski","year":"2009","journal-title":"Am. J. Surg."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1237","DOI":"10.1007\/s10459-015-9599-8","article-title":"Measuring cognitive load during simulation-based psychomotor skills training: Sensitivity of secondary-task performance and subjective ratings","volume":"20","author":"Haji","year":"2015","journal-title":"Adv. Health Sci. Educ."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"258","DOI":"10.1097\/01.mlg.0000248246.09498.b4","article-title":"Using a virtual reality temporal bone simulator to assess otolaryngology trainees","volume":"117","author":"Zirkle","year":"2007","journal-title":"Laryngoscope"},{"key":"ref_16","doi-asserted-by":"crossref","unstructured":"Zhou, Y., Bailey, J., Ioannou, I., Wijewickrema, S., O\u2019Leary, S., and Kennedy, G. (2013, January 6\u20138). Pattern-based real-time feedback for a temporal bone simulator. Proceedings of the 19th ACM Symposium on Virtual Reality Software and Technology, Singapore.","DOI":"10.1145\/2503713.2503728"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"2","DOI":"10.1186\/s41747-017-0033-2","article-title":"Through the HoloLens\u2122 looking glass: Augmented reality for extremity reconstruction surgery using 3D vascular models with perforating vessels","volume":"2","author":"Pratt","year":"2018","journal-title":"Eur. Radiol. Exp."},{"key":"ref_18","unstructured":"Hamza-Lup, F.G., Rolland, J.P., and Hughes, C. (2018). A distributed augmented reality system for medical training and simulation. arXiv."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"279","DOI":"10.2147\/AMEP.S201640","article-title":"Augmented reality glasses improve adherence to evidence-based intubation practice","volume":"10","author":"Alismail","year":"2019","journal-title":"Adv. Med. Educ. Pract."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"18","DOI":"10.1109\/MCSE.2020.2972822","article-title":"Augmented and virtual reality in surgery","volume":"22","author":"Desselle","year":"2020","journal-title":"Comput. Sci. Eng."},{"key":"ref_21","doi-asserted-by":"crossref","unstructured":"Dwivedi, S., Hayes, J., Pedron, I., Kang, J., Brenner, L.J., Barnes, C., Bailly, A., Tanous, K., Nelson, C., and Moats, J. (2022, January 10\u201314). Comparing the efficacy of AR-based training with video-based training. Proceedings of the Human Factors and Ergonomics Society Annual Meeting, Atlanta, GA, USA.","DOI":"10.1177\/1071181322661289"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"23","DOI":"10.1159\/000381252","article-title":"Factors associated with adverse events during tracheal intubation in the NICU","volume":"108","author":"Foglia","year":"2015","journal-title":"Neonatology"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"62","DOI":"10.1016\/j.jpeds.2015.09.077","article-title":"Endotracheal intubation in neonates: A prospective study of adverse safety events in 162 infants","volume":"168","author":"Hatch","year":"2016","journal-title":"J. Pediatr."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"e821","DOI":"10.1542\/peds.2012-2127","article-title":"National Emergency Airway Registry for Children Investigators and Pediatric Acute Lung Injury and Sepsis Investigators Network. Level of trainee and tracheal intubation outcomes","volume":"131","author":"Sanders","year":"2013","journal-title":"Pediatrics"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"1124","DOI":"10.1111\/anae.12367","article-title":"Transfer of airway skills from manikin training to patient: Success of ventilation with facemask or LMA-SupremeTM by medical students","volume":"68","author":"Russo","year":"2013","journal-title":"Anaesthesia"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"640","DOI":"10.1016\/j.surg.2010.01.007","article-title":"Increased stress levels may explain the incomplete transfer of simulator-acquired skill to the operating room","volume":"147","author":"Prabhu","year":"2010","journal-title":"Surgery"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"133","DOI":"10.1016\/S0300-9572(03)00179-5","article-title":"Utilization of virtual reality for endotracheal intubation training","volume":"59","author":"Mayrose","year":"2003","journal-title":"Resuscitation"},{"key":"ref_28","first-page":"91","article-title":"Virtual airway skills trainer (VAST) simulator","volume":"220","author":"Demirel","year":"2016","journal-title":"Stud. Health Technol. Inform."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"231","DOI":"10.1097\/SIH.0b013e3181514049","article-title":"Endotracheal intubation: Application of virtual reality to emergency medical services education","volume":"2","author":"Mayrose","year":"2007","journal-title":"Simul. Healthc."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"127","DOI":"10.1080\/10255840008908001","article-title":"A biomechanical model of the upper airways for simulating laryngoscopy","volume":"4","author":"Rodrigues","year":"2001","journal-title":"Comput. Methods Biomech. Biomed. Eng."},{"key":"ref_31","unstructured":"Meng, Y. (2018, January 1\u20135). VR Enhanced Interactive Intubation Simulation. Proceedings of the International Conference on Modeling, Simulation and Visualization Methods (MSV). The Steering Committee of The World Congress in Computer Science, Computer Engineering and Applied Computing (WorldComp), Las Vegas, NV, USA."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"101","DOI":"10.1111\/1467-9280.00318","article-title":"Virtually perfect time sharing in dual-task performance: Uncorking the central cognitive bottleneck","volume":"12","author":"Schumacher","year":"2001","journal-title":"Psychol. Sci."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"351","DOI":"10.1007\/BF02213420","article-title":"Instructional control of cognitive load in the training of complex cognitive tasks","volume":"6","author":"Paas","year":"1994","journal-title":"Educ. Psychol. Rev."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"37","DOI":"10.1016\/B978-0-12-387691-1.00002-8","article-title":"Cognitive load theory","volume":"Volume 55","author":"Sweller","year":"2011","journal-title":"Psychology of Learning and Motivation"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"e867","DOI":"10.3109\/0142159X.2012.714886","article-title":"Comparative effectiveness of instructional design features in simulation-based education: Systematic review and meta-analysis","volume":"35","author":"Cook","year":"2013","journal-title":"Med. Teach."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"103713","DOI":"10.1016\/j.apergo.2022.103713","article-title":"Dual-task interference while receiving information on a head mounted display and manual tracking with and without auditory warnings","volume":"101","author":"Ward","year":"2022","journal-title":"Appl. Ergon."},{"key":"ref_37","unstructured":"Neter, J., Kutner, M.H., Nachtsheim, C.J., and Wasserman, W. (1996). Applied Linear Statistical Models, McGraw-Hill\/Irwin."},{"key":"ref_38","unstructured":"Ralston, A., and Wilf, H.S. (1960). Mathematical Methods for Digital Computers, Wiley."}],"container-title":["Virtual Worlds"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2813-2084\/4\/2\/20\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,9]],"date-time":"2025-10-09T17:35:49Z","timestamp":1760031349000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2813-2084\/4\/2\/20"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,5,20]]},"references-count":38,"journal-issue":{"issue":"2","published-online":{"date-parts":[[2025,6]]}},"alternative-id":["virtualworlds4020020"],"URL":"https:\/\/doi.org\/10.3390\/virtualworlds4020020","relation":{},"ISSN":["2813-2084"],"issn-type":[{"type":"electronic","value":"2813-2084"}],"subject":[],"published":{"date-parts":[[2025,5,20]]}}}