Mental Imagery to Enhance Procedural Skills in Peripheral Venous Catheterization: A Randomized Simulation Study in Medical Students

Introduction

The acquisition of procedural skills is a cornerstone of medical education, essential for future clinical practice. With increasing pressures on clinical training time and a growing emphasis on patient safety, the exploration of supplementary and innovative pedagogical methods to enhance procedural competence is essential.

Mental imagery, defined as the cognitive rehearsal of a task in the absence of actual physical execution, has been established as a valuable technique for enhancing performance across various domains requiring complex psychomotor skills, such as sports [1, 2, 3]. Through the activation of neural networks similar to those involved in physical practice, mental imagery facilitates the consolidation of procedural knowledge, enhances cognitive and motor performance, and offers significant potential for optimizing the acquisition and refinement of technical skills in medicine and surgery [4, 5]. Mental imagery is also recognized for its cost-effectiveness and safety [6], as it does not necessitate expensive equipment.

In this context, mental imagery has garnered increasing attention within medical education [7]. In surgical practice, mental rehearsal is often used intuitively by experienced surgeons to prepare for procedures [8]. Several prospectives studies suggest that mental rehearsal can positively impact the acquisition and retention of surgical or procedural skills [5, 6, 9, 10, 11, 12]. Systematic reviews have further indicated that mental practice may contribute to technical performance enhancement, stress management, and learner confidence [13, 14].

Beyond individual technical skills, mental imagery could enhance collective team performance, particularly in high-risk situations. For instance, a randomized simulation study demonstrated that mental imagery could improve teamwork competencies more effectively than traditional simulation-based instruction in the context of emergency trauma care [15].

However, the overall body of evidence remains heterogeneous, and the extent to which mental imagery can be systematically integrated into routine medical training warrants further investigation [16].

The acquisition of procedural skills constitutes a core element of the education of healthcare professionals, including those in medical, surgical, and nursing schools. Given that many technical procedures inherently expose patients to risks of discomfort or harm, the development of modern, safer educational strategies has become essential. Among these skills, peripheral venous catheter (PVC) insertion represents one of the most frequently performed procedures, playing a critical role in the administration of intravenous therapies across diverse clinical settings. To date, the specific application of mental imagery to the learning of PVC insertion has been the subject of limited investigation, with a single study reporting promising outcomes, thereby highlighting the need for further research in this area [10].

The aim of this study was to evaluate the impact of pre-procedural mental imagery on procedural performance during PVC insertion in a mannequin-based simulation among fifth-year medical students.

Methods

Results

During the 2024–2025 academic year, we included a total of 64 fifth-year medical students from the Nîmes Faculty of medicine (Figure 1). 32 students were not available to participate. 33 students were allocated to the mental imagery arm and 31 to the control arm. In the mental imagery group, nearly half of the participants (48%) had no prior experience, compared to 29% in the control group (Table 1). Conversely, a greater proportion of participants in the control group reported intermediate (2–5 procedures: 29%) or higher levels of experience (>10 procedures: 9.7%) than in the mental imagery group (18% and 6.1%, respectively). These differences suggest that the control group was overall more experienced in PVC insertion. No other differences were observed at baseline in the demographic characteristics of the two groups (Table 1).

Figure 1

The uncomplicated first-puncture success rate was statistically higher in the mental imagery versus control group, occurring in 25 (76%) versus 16 (52%), respectively (OR = 2.93 [1.03–8.81]; p = 0.04) (Figure 2). In the multivariable analysis adjusting for baseline experience (“Novice” versus “Non-Novice”), the mental imagery group remained significantly associated with a higher uncomplicated first-puncture success rate (adjusted OR = 3.02 [1.04 to 9.40]; p = 0.047). In this model, being experienced was not independently associated with higher success (p = 0.80). Furthermore, no significant interaction was found between the intervention and experience level (p for interaction = 0.25). The median number of punctures was significantly lower in the mental imagery compared to the control group (1 [1–1] versus 1 [1–3], respectively; p = 0.03) (Figure 3). The composite outcome of complications was statistically lower in the mental imagery versus control group, occurring in 0 (0%) versus 4 (12.9%), respectively (p < 0.05). Non-functioning perfusion occurred in 0 (0%) and 3 (9.7%) cases in the mental imagery versus control group, respectively (p = 0.11). Failure occurred in 0 (0%) and 1 (3.2%) case in the mental imagery versus control group, respectively (p = 0.48). No arterial puncture occurred in either group. The adapted MIQ score before the procedural workshop was not statistically different between the control and the mental imagery groups (34 [27–37] versus 32 [22–35], respectively; p = 0.20). Both groups showed a significant improvement in their MIQ scores after the workshop (p < 0.001 for both). However, the magnitude of this improvement was significantly greater in the mental imagery group. The median increase in adapted MIQ score was significantly greater in the mental imagery group compared to the control group (+17 [12–22] versus +11 [8–18], respectively; p = 0.004). The estimated median difference between groups was +5 [2 to 8] (Figure 4). The adapted MIQ demonstrated excellent internal reliability in our sample, with a Cronbach’s alpha of 0.90 at baseline and 0.88 after the workshop. Detailed results of the adapted MIQ score were reported in Supplementary Table S1.

Figure 2

Figure 3

Figure 4

Discussion

This monocentric, randomized controlled simulation study demonstrates that a single mental imagery session performed prior to PVC procedure significantly improved uncomplicated first-puncture success rates among medical students. Moreover, this intervention was associated with a significant reduction in complications and enhanced the perceived quality of mental imagery, as evidenced by a significantly greater increase in adapted MIQ scores in the mental imagery group. This finding suggests that the quality of mental imagery may be a key mediator of the intervention’s effectiveness. Interestingly, despite a lower level of prior experience with PVC insertion in the mental imagery group, participants in this group achieved better outcomes, suggesting that mental imagery may compensate for limited practical experience and enhance procedural performance even among novices.

Non-technical interventions, such as cognitive training and mental imagery, are increasingly recognized as effective strategies to improve procedural performance and patient safety in medical education [7]. However, evidence regarding their specific impact on technical performance acquisition, particularly in the context of simulation-based learning, remains limited.

The relevance of mental imagery in procedural learning is further supported by the meta-analysis conducted by Sattelmayer et al. [14], which identified mental practice as one of the most promising motor learning strategies in medical and surgical education. Although individual randomized trials in this field often lack statistical power, this meta-analysis provides valuable evidence for the efficacy of such interventions.

Our findings complement those of Collet et al. [10], who investigated the effect of mental imagery on the learning curve for PVC insertion over multiples training sessions. Interestingly, their study also employed the MIQ scale to assess the quality of mental imagery, similar to our approach. In their study, medical students in the mental imagery group gained technical skills after four sessions, whereas those in the control group required five sessions to reach comparable performance. However, the beneficial effects reported by Collet et al. appeared to be confined primarily to the early phase of skill acquisition, suggesting that mental imagery may have the greatest impact during the initial learning stages rather than on later refinement of performance. A critical limitation of their study is the choice of procedural speed as the main outcome to validate learning curve progression. Although faster execution can reflect a certain level of technical expertise, speed alone is not necessarily a reliable surrogate for procedural quality or patient-centered outcomes.

Our study presents several strengths that reinforce the validity and relevance of its findings. First, the randomized controlled design enhances both the internal and external validity of the findings. Second, in contrast to previous research focusing primarily on learning procedures or skill acquisition [13], our work is, to our knowledge, the first simulation trial to specifically assess the direct impact of mental imagery on procedural performance, defined by clinically meaningful safety outcomes, regardless of the learner’s initial skill level. By selecting uncomplicated first-puncture success rate and complication incidence as primary and secondary outcomes, we deliberately emphasized performance quality rather than learning progression alone. This distinction is particularly relevant considering the umbrella review conducted by Snelgrove et al. [13], which highlighted a major gap in the existing body of evidence on motor learning interventions in health professions education. The authors demonstrated that most previous studies have focused on the early phases of skill acquisition, often evaluating knowledge acquisition or behavioral change, while rarely addressing higher-level outcomes such as actual performance improvement or patient benefit. This observation aligns with Kirkpatrick’s model of educational outcomes, in which the ultimate levels (Level 3: behavior, and Level 4: results) remain the least explored in procedural skill research [22]. By focusing on procedural success and complication rates, our study directly addresses these higher levels of Kirkpatrick’s framework, thereby offering evidence of the potential clinical relevance of mental imagery beyond its effect on learning dynamics.

Several limitations of this study should be acknowledged. First, due to the nature of the study design, the study was conducted in an open-label setting, and both investigators and participants were aware of the group allocation. To minimize the risk of assessment bias, we selected objective and pragmatic primary and secondary outcomes. However, we acknowledge that the participants’ awareness of the intervention may have introduced a performance bias (Hawthorne effect), leading to increased focus in the mental imagery group. Second, the intervention group received a dedicated guided mental imagery session immediately prior to the procedure. While all participants viewed a standardized instructional video on PVC insertion in the days preceding the workshop to equalize baseline knowledge, the control group did not perform an attention-matched neutral task immediately before the simulation. Therefore, we cannot exclude that the benefits observed were partly influenced by an enhanced immediate focus in the intervention group. Third, the voluntary nature of participation might induce a selection bias favoring motivated students. However, this does not affect the internal comparison between groups, and the study sample remains representative of the target audience of active learners willing to engage in simulation training. Finally, procedural performance was assessed at a single time point, immediately following the intervention. The persistence of the observed benefits over time was not evaluated, and therefore the durability of the effect of mental imagery on PVC insertion skill retention remains to be determined.

Future research should address these issues by focusing on both immediate and long-term outcomes, assessing the sustainability of mental imagery effects on procedural performance over extended periods. Prior work has suggested that the benefits of mental practice may decline without reinforcement over time [23]. Given its ease of implementation and minimal resource requirements, mental imagery represents a particularly attractive strategy for promoting long-term retention, especially when integrated through repeated sessions over time. Investigating the optimal frequency and duration of mental imagery practice, including the potential additive effect of multiple sessions, therefore represents a key area for future studies in procedural training. While mental imagery is already well established in surgical education, its potential role in the acquisition and reinforcement of other invasive procedural skills, such as central venous catheterization, lumbar puncture, or endotracheal intubation, remains largely unexplored. Integrating mental practice into the training of these high-risk procedures could offer a valuable, low-cost adjunct to traditional simulation-based methods, with the potential to enhance both technical performance and safety outcomes across a wide range of clinical contexts.

Conclusion

Mental imagery appears to be an effective, safe, and low-cost educational strategy, not only for enhancing the acquisition of procedural skills, but also for improving simulation-based performance.

Future studies should investigate the impact of mental imagery on other invasive procedures and non-procedural competencies and assess the sustainability of these benefits.

Data Accessibility Statement

The dataset used and analyzed during the current study is available from the corresponding author on reasonable request.

Additional File

The additional file for this article can be found as follows:

Ethics and Consent

Ethics approval: Institutional Review Board approval number 24.11.07 (Nimes University Hospital).

Clinicaltrials.gov: NCT06932822.

Consent to participate, consent for publication: All students received an information letter and agreed to participate for free.

Competing Interests

The authors have no competing interests to declare.

Author Contributions

NB: Conceptualization, Methodology, Formal analysis, Data Curation, Writing – Original Draft.

HN: Conceptualization, Methodology, Data Curation, Writing – Original Draft.

MM: Methodology, Formal analysis, Writing – Review & Editing.

LS: Conceptualization, Writing – Review & Editing.

DM: Conceptualization, Writing – Review & Editing.

CR: Conceptualization, Methodology, Writing – Review & Editing, Supervision.