Training characteristics, perceived proficiency, and facilitators of intubation among emergency medicine residents in Saudi Arabia: a multi-center cross-sectional study

Introduction

Endotracheal intubation is a fundamental and life-saving procedure in emergency medicine, often performed under critical circumstances where time and precision are essential (1). The ability to secure an airway quickly and successfully can significantly influence patient outcomes, making intubation proficiency an essential competency for every emergency physician. Mastery of this skill requires not only theoretical knowledge but also extensive practical experience, cognitive readiness, and the ability to adapt to diverse clinical scenarios (2). As the primary providers of airway management in the emergency department, emergency medicine residents must develop this competence progressively throughout their training years (3, 4). However, data on intubation training characteristics and proficiency among emergency medicine residents in Saudi Arabia remain limited, and it is unclear how current training practices align with international benchmarks.

The pathway to achieving intubation proficiency is complex and multidimensional. It involves repeated exposure to airway procedures, constructive supervision, and familiarity with various intubation devices and techniques (5, 6). In recent years, the landscape of airway management has evolved considerably with the widespread adoption of video laryngoscopy, which offers improved glottic visualization compared to traditional direct laryngoscopy. Its use has been associated with higher first-pass success rates in several studies, particularly among trainees and in difficult airway scenarios (7–9). This technological advancement has prompted discussions about its impact on training, success rates, and the learning curve among novice practitioners (10, 11).

Therefore, the Saudi context necessitates dedicated investigation into the unique structure of residency training, the diversity of clinical settings, and the demographic characteristics of trainees. Understanding how residents perceive their own proficiency, what factors they believe contribute to successful intubation, and how these perceptions evolve across different stages of training is essential for identifying gaps in current educational practices.

Accordingly, this study aimed to describe intubation training characteristics, perceived proficiency, and facilitators among emergency medicine residents in Saudi Arabia, and to compare these factors across postgraduate year levels. The findings are intended to provide insights for program directors and educators to enhance airway training and improve patient care outcomes.

Methods

Study design and setting

This multi-center, cross-sectional study was conducted among emergency medicine residents enrolled in the Saudi Board of Emergency Medicine training program. The study was carried out across multiple training centers in Saudi Arabia, including major cities such as Riyadh, Jeddah, Dammam, and others. The setting included hospitals affiliated with the Saudi Commission for Health Specialties (SCFHS) that provide structured emergency medicine residency training, regardless of whether they were governmental or private, as the key factor was board accreditation. Data collection took place over a three-month period from mid-June to mid-September 2025.

Participants/inclusion and exclusion criteria

Included in this study were male and female residents currently registered in the Saudi Board Emergency Medicine residency program, actively undergoing training at any accredited center in Saudi Arabia at the time of the study, and consenting to participate. Excluded from this study were non-emergency medicine residents, those with incomplete survey responses defined as missing data on key variables, and residents who had already completed their training.

Sample size

Based on the total number of registered emergency medicine residents in the Saudi Board program across multiple cities, which was 896 residents in 2025, a target sample size of at least 300 residents was estimated. This calculation was based on a 95% confidence level and a 5% margin of error, ensuring adequate representation of different training levels and geographic regions. The final sample included 100 complete responses. Similar to many survey-based studies involving residents, competing clinical responsibilities, shift work schedules, and survey fatigue likely contributed to lower participation rates.

Procedure and data collection

A structured electronic survey was developed specifically for this study. The questionnaire was compiled using Google Forms and distributed electronically to emergency medicine residents via their mobile phones and institutional email addresses. Participation was voluntary, and no incentives were offered.

The questionnaire was divided into several sections to capture comprehensive data: The questionnaire was developed by the research team following a focused review of the literature on airway management training, intubation proficiency, and emergency medicine residency education. While the survey was not directly adapted from a previously validated questionnaire, several domains were informed by concepts commonly explored in prior airway training studies. The survey content was reviewed by emergency medicine physicians with experience in airway management and residency training to assess relevance, clarity, and appropriateness of the included items. The final questionnaire was administered in English, which is the standard language of medical education and residency training within Saudi Board emergency medicine programs.

• Section 1: Demographic and Training Characteristics: This section collected data on postgraduate year level (PGY-1 to PGY-4) and geographic region of training (Central, Southern, Eastern, Western, Northern).
• Section 2: Intubation Training Experience: Residents were asked about the number of failed intubation attempts before feeling proficient (categorized as less than 10, 10–20, 20–40, more than 40, or still not confident intubating alone). They were also asked to self-estimate their first-pass intubation success rate as a percentage.
• Section 3: Device Preferences: Residents indicated their preferred intubation device, with options including video laryngoscope (e.g., GlideScope, C-MAC), direct laryngoscope (Macintosh), or no preference/case-dependent.
• Section 4: Perceived Facilitators of Intubation: This multiple-response question allowed residents to select factors they believed facilitated successful intubation from a list including proper positioning, video laryngoscope use, good supervision, bougie use, and simulation training. A free-text “other” option was also available.
• Section 5: Perceived Adequacy of Training: Residents were asked whether they believed their program provided sufficient supervised intubation opportunities (yes/no).

The survey was pilot-tested on a small sample of residents to assess clarity, comprehension, and ease of completion. The pilot group consisted of 5 emergency medicine residents who did not participate in the final study to reduce potential bias. Minor modifications were made based on feedback before full distribution.

The questionnaire was intentionally designed as a multidomain descriptive instrument rather than a psychometric scale measuring a single latent construct. The survey items addressed distinct domains, including demographic characteristics, procedural exposure, device preferences, perceived facilitators, confidence, and adequacy of supervision. Because these items were not intended to measure one internally consistent construct, calculation of Cronbach's alpha was considered methodologically inappropriate, as internal consistency testing assumes conceptual homogeneity among items.

Ethical considerations

This study was conducted in accordance with the ethical principles of the Declaration of Helsinki. Ethical approval was obtained from the Institutional Review Board of King Abdullah International Medical Research Center prior to data collection (Approval Number: NRR25/021/6). All participants provided electronic informed consent before accessing the survey. The consent form explained the purpose of the study, the voluntary nature of participation, the anonymity of responses. No personal identifiers were collected, and all data were stored securely on password-protected devices accessible only to the research team.

Statistical analysis

All statistical analyses were performed using IBM SPSS Statistics for Windows, Version 28.0 (IBM Corp., Armonk, NY, USA). Prior to analysis, the distribution of continuous variables was assessed using the Shapiro–Wilk test for normality. Given that the outcome variable (self-estimated first-pass intubation success rate) did not conform to a normal distribution, non-parametric methods were used. Continuous data are presented as median with interquartile range (IQR; Q1-Q3). Comparisons of continuous variables across PGY levels were conducted using the Kruskal–Wallis H test, with post-hoc pairwise comparisons conducted where appropriate using Bonferroni correction. Categorical variables are presented as absolute frequencies and percentages. Comparisons across PGY levels for categorical variables were performed using the Chi-square (χ²) test. When expected cell counts were fewer than five, Fisher's Exact Test was applied as the appropriate alternative. Statistical significance was defined as a two-tailed p-value of less than 0.05 for all analyses.

Results

The baseline demographic and training characteristics of the study sample are presented in Table 1. A total of 100 emergency medicine residents participated in the study, with a relatively even distribution across postgraduate year levels: PGY-1 (30%), PGY-2 and PGY-3 (23% each), and PGY-4 (24%). The vast majority of residents were training in the Central region (87%), followed by the Southern region (8%), with the Eastern, Western, and Northern regions each representing 2% or less of the sample. Regarding the number of failed intubation attempts before feeling proficient, more than half of the residents (58%) reported less than 10 attempts, while 16% required 10 to 20 attempts, 5% required 20 to 40 attempts, and 2% required more than 40 attempts. Notably, 19% of respondents stated that they still do not feel confident intubating alone. When asked about their preferred intubation device, the majority (66%) indicated a preference for a video laryngoscope, such as a GlideScope or C-MAC. A direct laryngoscope (Macintosh) was preferred by 14%, and 20% reported having no preference or that their choice depends on the case. Residents were also asked to select factors that facilitate intubation in a multiple-response question. Proper positioning was the most frequently cited factor, identified by 85% of participants. The use of a video laryngoscope was the next most common facilitator (71%), followed by good supervision (43%), use of a bougie (32%), and simulation training (30%). A majority of residents (76%) perceived that their program provides adequate supervised intubation opportunities. Finally, the residents’ self-estimated first-pass intubation success rate had a median of 80%, with an interquartile range from 70% to 90%.

Table 1. Demographic and training characteristics of emergency medicine residents (N = 100).

IQR, interquartile range; Q1, first quartile; Q3, third quartile.

A comparison of intubation training characteristics and perceptions across postgraduate year levels is presented in Table 2. The median self-estimated first-pass success rate showed an increasing trend with higher training levels, from 70% among PGY-1 residents to 80% among PGY-3 and PGY-4 residents; however, this difference did not reach statistical significance (p = 0.143). A statistically significant association was observed between PGY level and the number of failed attempts before feeling proficient (p < 0.001). Among PGY-1 residents, 56.7% reported requiring fewer than 10 failed attempts, while 36.7% stated they still did not feel confident intubating alone. In contrast, no PGY-3 or PGY-4 residents reported a lack of confidence (Figure 1), with the majority in these senior levels indicating they felt proficient after fewer than 10 failed attempts (69.6% and 58.3%, respectively). No significant difference was found across PGY levels regarding preference for intubation device (p = 0.537). The video laryngoscope remained the most frequently preferred device across all years, although the proportion decreased from 76.7% among PGY-1 residents to 50% among PGY-4 residents (Figure 2). Analysis of factors perceived to facilitate intubation revealed a significant association only for good supervision (p < 0.001), which was cited by 66.7% of PGY-1 residents but only 12.5% of PGY-4 residents. No significant differences were observed across training levels for the other facilitating factors, including video laryngoscope use, simulation training, bougie use, or proper positioning. Finally, a statistically significant association was found between PGY level and the perception that the program provides sufficient supervised intubation opportunities (p = 0.048), with PGY-3 residents reporting the highest level of agreement at 95.7%.

Table 2. Comparison of intubation training characteristics and perceptions across postgraduate year levels.

Statistically significant (p < 0.05). Fisher's exact test was used for categorical variables with expected cell counts <5: “Failed Attempts Before Feeling Proficient”, “Preferred Intubation Device”, and the “Proper positioning” factor within “Factors Facilitating Intubation”. The chi-square test was used for all other categorical variables (“Good supervision”, “Video laryngoscope”, “Simulation training”, “Bougie”, “Program Provides Sufficient Supervised Opportunities”). The Kruskal–Wallis H test was used for the continuous variable “Self-Estimated First-Pass Success Rate”. IQR, interquartile range.

Discussion

The ability to perform endotracheal intubation safely and competently is a cornerstone of emergency medicine practice, yet the pathway to achieving this proficiency during residency training remains incompletely characterized in many settings, including Saudi Arabia. This multi-center cross-sectional study was designed to address this gap. Our findings provide a nuanced understanding of how residents acquire airway skills, what they perceive as most helpful to their learning, and how these perceptions evolve with increasing clinical experience.

One of the most notable findings was the substantial proportion of residents who reported lacking confidence in intubating alone. This finding is concerning, as self-confidence in procedural skills is an important component of clinical competence and readiness for independent practice. The lack of confidence among a notable minority of residents may reflect gaps in clinical exposure, insufficient supervised practice, or variability in the quality of instruction across different training sites. Confidence in airway management is particularly critical given that intubation is often performed under time-sensitive and high-stakes conditions (12). Residents who lack confidence may hesitate when faced with difficult airways, potentially leading to delayed interventions or reliance on others to secure the airway. Alternatively, this finding may also indicate that some residents have a realistic appraisal of their skills and recognize that they require more practice before feeling competent, a form of metacognitive awareness that is itself an important aspect of professional development. From an educational perspective, this finding has several practical implications. Program directors should consider implementing targeted remediation, structured feedback, or increased supervised practice opportunities for residents who continue to feel unprepared. The integration of cognitive aids such as checklists and algorithms may also help improve provider confidence and reduce anxiety in emergency airway management (13). Furthermore, structured protocols for rapid sequence intubation, including standardized preoxygenation, may enhance trainee confidence and performance (14). Emergency physicians are often the first responders to critically ill patients requiring immediate airway intervention, making this subgroup particularly important to identify and support.

When residents were asked about factors they perceive as facilitating successful intubation, proper positioning was recommended by 85% of participants, making it the most frequently cited facilitator. This suggests that basic airway principles are being effectively communicated during training. However, awareness alone does not guarantee implementation. This gap between knowledge and practice has been documented in Saudi Arabia, where only 19.5% of physicians utilized the head-up position during rapid sequence intubation in a recent survey (15). Program directors should therefore consider emphasizing practical application alongside theoretical teaching to ensure that positioning principles are consistently implemented at the bedside. Similarly, the preference for video laryngoscopy among residents reflects the widespread adoption of this technology in current airway management. This preference among trainees for video laryngoscopy may be a natural consequence of its design, which facilitates teaching by allowing the supervisor to share the same view as the trainee, a concept supported by a meta-analysis which demonstrated that video laryngoscopy is an effective and preferred tool for teaching direct laryngoscopy skills (10). Although earlier local data suggested a preference for direct laryngoscopy (16), the strong current preference for video laryngoscopy carries potential risks, as it may reduce confidence or experience with direct laryngoscopy, leaving trainees underprepared for settings where the device is unavailable such as prehospital environments, resource-limited facilities, or during equipment failure (17). Educators must therefore ensure that residents achieve competence in both modalities.

Consistent with our finding that video laryngoscopy was perceived as a key facilitator, previous studies have reported that video laryngoscopy is associated with improved first-pass success and outperforms direct laryngoscopy across training levels (18, 19). These findings reinforce that while video laryngoscopy is a valuable educational and performance tool, training curricula must intentionally incorporate direct laryngoscopy to ensure residents are versatile and prepared for all clinical scenarios.

Good supervision was identified as a facilitator by 43% of residents, highlighting its ongoing importance in airway training. Effective supervision provides a safety net for trainees, allows for real-time corrective feedback, and fosters a learning environment where residents can practice with appropriate guidance. This finding underscores the need for programs to maintain strong supervisory structures, particularly for junior residents who are in the earliest stages of skill acquisition. The decline in perceived importance of supervision with advancing training levels (from 66.7% among PGY-1 to 12.5% among PGY-4) reflects the natural progression toward autonomy, but also suggests that even senior residents may benefit from supervisory input during complex or high-risk intubations. Structured supervision should therefore be viewed not merely as a safety measure but as a core educational strategy that supports progressive skill development (20, 21).

The median self-estimated first-pass intubation success rate was 80% (IQR = 70%–90%), indicating substantial variability in perceived proficiency across the cohort. This range aligns with objectively measured first-pass success rates reported in international studies, which typically range from 70% to 90% depending on setting and operator experience (19, 22–25). While this consistency suggests that residents may have a realistic understanding of their abilities, self-perception does not replace direct observation of performance. For residency training, this finding highlights the importance of regular, objective assessment of procedural competence rather than relying solely on self-reported confidence. Residents who perceive themselves as falling below the threshold may represent a group that requires additional focused training, and programs should proactively identify these individuals through direct observation and feedback. The consistency of our self-reported data with objectively measured international benchmarks suggests that residents have a realistic understanding of their abilities, though self-perception does not replace direct observation of performance; however, direct comparison is limited because our outcome was self-reported. The residents who perceive themselves as falling below this threshold may represent a group that requires additional focused training.

While 76% of residents perceived that their program provides sufficient supervised intubation opportunities, nearly one-quarter (24%) disagreed. This finding is significant because supervised practice is essential for developing procedural competence. The reasons for this perception were not directly investigated in this study, but the finding itself highlights an important area for programmatic attention. Programs should therefore regularly assess the adequacy of procedural exposure and consider strategies such as simulation-based training to supplement clinical opportunities where gaps exist, though the effectiveness of simulation was not directly tested in this study. In the context of the COVID-19 pandemic, the feasibility and acceptability of simulation-based airway management training have been demonstrated in the Saudi context, with over 90% of participants finding it relevant and essential (26). Additionally, simulation-based education has been shown to significantly improve knowledge, skills, and perceived confidence in emergency airway management (27).

When examining differences across postgraduate year levels, several important patterns emerged. A statistically significant association was found between PGY level and the number of failed attempts before feeling proficient (p < 0.001). Specifically, 36.7% of PGY-1 residents reported lacking confidence in intubating alone, whereas no PGY-3 or PGY-4 residents endorsed this lack of confidence. This finding aligns with the expected trajectory of skill acquisition during residency, wherein confidence and competence develop progressively with accumulated clinical experience. The fact that all senior residents ultimately achieved confidence is reassuring, though confidence is not equivalent to objective competence. This suggests that, from the residents’ perspective, the current training structure appears to support the development of greater confidence in independent airway management by the senior years of training. However, the high proportion of PGY-1 residents lacking confidence underscores the need for intensive supervision and structured support during the early years of training. This finding is consistent with the literature, where clinical experience has been identified as an independent predictor of first-pass success, with success rates improving progressively with advancing training (19, 23).

The perceived importance of good supervision declined significantly with advancing training level (p < 0.001), from 66.7% among PGY-1 residents to only 12.5% among PGY-4 residents. This pattern reflects the natural progression toward autonomy that characterizes residency training. Junior residents, who are still acquiring foundational skills, naturally value the guidance and safety net provided by supervisors. As residents gain experience and successfully manage a variety of airway scenarios, they develop greater self-reliance and may view supervision as less essential to their success. While this decline is expected, it also raises a subtle but important consideration: even experienced residents may benefit from supervisory input during particularly complex or high-risk intubations. Programs should foster a culture that encourages seeking help regardless of training level, as this is likely to support safe practice and promote continuous learning. However, the direct impact on patient safety outcomes was not assessed in this study and should be explored in future research using objective clinical measures. This is particularly critical given that multiple intubation attempts have been associated with a higher prevalence of adverse events, including cardiac arrest and bleeding (28). This underscores that even for experienced providers, a “safety first” approach that welcomes supervision in complex cases is critical to preventing patient harm.

Although not statistically significant, the trend toward decreasing video laryngoscope preference with seniority is educationally meaningful. This pattern may indicate that senior residents develop greater versatility and comfort with multiple devices, including direct laryngoscopy, as they accumulate more clinical experience. Alternatively, it could reflect that training programs intentionally emphasize direct laryngoscopy in later years to ensure that residents are not overly reliant on video technology. Either interpretation suggests that device preference is dynamic and evolves with experience, highlighting the importance of providing balanced exposure to both video and direct laryngoscopy throughout residency. This developmental trajectory is supported by the findings of the National Emergency Airway Registry study by Garcia et al. (2023), which reported that first-attempt success with direct laryngoscopy improved significantly with advancing training, while video laryngoscopy success also improved but remained higher overall (19).

Similarly, the median self-estimated first-pass success rate increased from 70% among PGY-1 to 80% among PGY-3 and PGY-4, though this difference did not reach statistical significance (p = 0.143). The lack of statistical significance may be attributable to the relatively small sample size within each PGY subgroup, which limits statistical power to detect modest differences. It is also possible that perceived success rates plateau earlier in training than actual success rates, with residents adjusting their self-perceptions as they encounter more difficult airways and develop a more nuanced understanding of their own abilities. Our finding of increasing self-estimated first-pass success with training level is consistent with the literature. Garcia et al. (2023) demonstrated progressive improvement in first-attempt success across PGY levels for all device types (19). Furthermore, Chan et al. (2020) reported a first-attempt success rate of 74.4% in a resident-staffed prehospital system, with overall success reaching 96.8%, supporting the concept of skill acquisition with experience (20).

Collectively, these findings offer actionable insights for program directors, educators, and policymakers seeking to enhance intubation training, improve resident confidence, and ultimately optimize patient outcomes in emergency settings across Saudi Arabia. Future research should prioritize prospective multicenter studies with objective assessment of intubation performance to validate self-reported findings, evaluation of simulation-based educational interventions, and establishment of a national airway registry for continuous quality improvement and benchmarking across training programs.

Strengths and limitations

This study has several notable strengths. The multi-center design, which included emergency medicine residents from multiple training centers across Saudi Arabia, theoretically enhances the generalizability of the findings, though this is limited by the geographic concentration of the sample (87% Central region). The use of a structured electronic survey allowed for standardized data collection and facilitated wide distribution to residents across various training programs. The inclusion of residents from all postgraduate year levels enabled a comprehensive comparison of training characteristics and perceptions across different stages of training, providing valuable insights into how confidence, device preferences, and perceived facilitators evolve with experience. Furthermore, the focus on self-estimated first-pass success rates, device preferences, and perceived facilitators directly addresses key educational outcomes that are relevant to program directors and educators seeking to improve airway training curricula. On the other hand, several limitations should be acknowledged. First, the study relied on self-reported data, which is subject to recall bias and social desirability bias; residents may have overestimated or underestimated their proficiency. Specifically, self-estimated first-pass success rates may not accurately reflect objectively measured first-pass success, and the two should not be equated. Second, the final sample size of 100 residents, while adequate for descriptive and comparative analyses, fell short of the target sample size of 300, which may have limited statistical power to detect smaller but potentially meaningful differences, particularly in subgroup analyses across PGY levels, and may also affect the representativeness of the findings. Additionally, because the exact number of residents who received the survey could not be determined, the precise response rate is unknown, but using the total registered population of 896 as a denominator suggests a low response rate, which further raises the possibility of non-response bias. Third, the study population was predominantly from the Central region (87%), reflecting a major geographic imbalance that substantially limits the generalizability of findings to residents training in other regions of Saudi Arabia. Therefore, the “multi-center” nature of the study should be interpreted with caution. Fourth, the cross-sectional design captures perceptions and experiences at a single point in time and does not allow for assessment of causality or longitudinal changes in confidence and proficiency over the course of training. Fifth, the variable “failed attempts before feeling proficient” combined attempt-based categories with a confidence-based option (“still do not feel confident intubating alone”), introducing conceptual overlap between procedural exposure and self-confidence. This limits the precision of this measure, and future studies should use more objective metrics such as total airway exposures or verified first-pass success rates. Finally, the exclusion of non-respondents and incomplete surveys may have introduced selection bias, as residents who chose to participate may have differed systematically from those who did not. Despite these limitations, the findings provide important foundational insights into intubation training among emergency medicine residents in Saudi Arabia and identify key areas for further investigation and educational intervention.

Conclusion

This multi-center cross-sectional study provides a preliminary characterization of self-reported intubation training perceptions among emergency medicine residents in Saudi Arabia, directly addressing its objectives to describe training characteristics, device preferences, perceived facilitators, and to compare these factors across postgraduate year levels. The findings reveal that while the majority of residents ultimately develop confidence and perceive their training favorably, a notable minority (19%) still lack confidence in intubating alone, and nearly one-quarter perceive insufficient supervised opportunities. Although video laryngoscopy was the preferred device overall, its preference declined with seniority, suggesting increasing device versatility with experience. Significant differences across PGY levels were observed in confidence, the perceived importance of supervision, and the adequacy of supervised opportunities, suggesting the PGY-2 year may be a transitional phase that could benefit from targeted support. These findings may offer preliminary insights that could help inform program directors and educators in considering enhancements to airway training curricula, the importance of structured supervision, and balanced exposure to both video and direct laryngoscopy. Ultimately, the findings may inform future training strategies aimed at supporting resident confidence and airway education. However, because this study relied on self-reported data, the direct effects on objective procedural competence or patient safety outcomes were not assessed and should be investigated in future prospective studies using objective performance measures.

Generative AI statement

The author(s) declared that generative AI was not used in the creation of this manuscript.

Any alternative text (alt text) provided alongside figures in this article has been generated by Frontiers with the support of artificial intelligence and reasonable efforts have been made to ensure accuracy, including review by the authors wherever possible. If you identify any issues, please contact us.

Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Footnotes

Edited by: Ozgur Karcioglu, University of Health Sciences, Türkiye

Reviewed by: Harun Yıldırım, Kutahya Health Sciences University, Türkiye

Mohamed Saad Rakab, Mansoura University, Egypt

Pedro Charco, La Fe Hospital, Spain