**6. Limitations**

This study did not compare the 3LC and traditional types of exercises. In earlier studies, 3LC had a significant impact on perceived collaboration, learning as well as performance. Based on these findings, before and after design control was chosen (pre- and post-test) [22–25]. Measuring the perceived e ffects of exercises, using a self-assessment tool, may be considered as a limitation. The possibility of over- or underreporting cannot be ignored. However, there are some advantages with the tool too, such as it encourages the participants to reflect over their own learning progress and performance, to be more responsible for their own learning, to develop their judgment skills while they have no pressure of peer evaluation, make participants more autonomous learners and finally make them aware of their weaknesses and strength. To verify the causality and generalizability of the results, a study that is not just based on a written test would give additional insightful and important information.

As an alternative, a comparative design, including a control group, should be considered in future studies. However, pre- and post-test scores provide information on whether or not participants have learned from the training. Besides, a well-designed pre- and post-test can help trainers understand which concepts or competencies were well taught during the training and which ones need additional time, or need to be covered using alternative methods [25,33]. Pre- and post-tests may not be the best tools to use for every type of training but still o ffer a good overview of the tested group's advancement. Wishing to understand what knowledge can be credited to the training itself, using a pre- and post-test methodology is essential. As shown statistically in this study, the knowledge of EPs in all areas of CSCATT increased significantly. Another limitation was that the data collection occurred immediately after the exercises and not supplemented with data collected weeks or months after the exercises [27,28].

An alternative method of evaluating learning, such as the observation of skills demonstrated in a role-play, might be more appropriate in some situations. In this study, we combined the Participant observation method as a complement to the pre- and post-course tests [26–29]. It is a variant of the natural observations model. Still, the researcher joins in and becomes part of the group they are studying to ge<sup>t</sup> a more in-depth insight into their activities. In this overt observation model, the researchers revealed their identity and purpose to the group and asked permission to observe. There are some limitations to this model. It can be challenging to ge<sup>t</sup> time/privacy for recording, which means observers have to wait until they are alone and rely on their memory, which is a problem as they may forget details and are unlikely to remember direct quotations. Furthermore, if the researcher becomes too involved, they may lose objectivity and become bias, and thus reduce the validity of the data.

The participants in this study were all physicians, while other sta ff such as nurses, paramedics, administrators, etc. are also important parts of a hospitals' MID management. This study was the first step in a series of studies that are planned to evaluate the concept of FSC, and physicians were simply chosen due to their actual position within the Thai healthcare and their knowledge in English. It is clear that other knowledgeable sta ff could also possess the leadership position [34].

Finally, although statistically significant results were obtained in this study, the number of included EPs can be challenged. However, for everyone working within healthcare, it is clear that a larger number of physicians cannot be gathered at the same time for any kind of exercise or training. This is a challenging fact that a ffects all types of education and training within all healthcare systems [21,35]. Similar argumen<sup>t</sup> is true concerning the provision of a control group. It is hard to ge<sup>t</sup> enough healthcare workers in a training session, and still harder to have one third of them as a control group. Simulation exercises emerged as a solution to this issue since reality-based exercises demand not only a large number of participants but also cost a lot and often evaluate just one part of the disaster managemen<sup>t</sup> chain [21,35].
