direct observation, coupled with the social expectation that residents should be responsible for ensuring observations occur, was identified as a key barrier. Additionally, competing demands identified across multiple TDF domains emerged as an important and pervasive theme. Conclusion: This study identified key barriers and enablers to direct observation. The influencing factors identified in this study provide a basis for the development of potential strategies aimed at embedding direct observation as a routine pedagogical practice in residency training. Keywords: direct observation, residency education, assessment LO38 Does spaced instructional design result in improved retention of pediatric resuscitation skills? A randomized education study C. Patocka, MD, MHPE, A. Cheng, MD, M. Sibbald, MD, MHPE, PhD, J. Duff, MD, A. Lai, MD, P. Lee-Nobbee, MD, H. Levin, MD, T. Varshney, MD, CM, B. Weber, MD, T. Abedin, MSc, F. Bhanji, MD, MSc (Ed), University of Calgary Cumming School of Medicine, Department of Emergency Medicine, Calgary, AB Introduction: Survival from cardiac arrest has been linked to the quality of resuscitation care. Unfortunately, healthcare providers frequently underperform in these critical scenarios, with a well-documented deterioration in skills weeks to months following advanced life support courses. Improving initial training and preventing decay in knowledge and skills are a priority in resuscitation education. The spacing effect has repeatedly been shown to have an impact on learning and retention. Despite its potential advantages, the spacing effect has seldom been applied to organized education training or complex motor skill learning where it has the potential to make a significant impact. The purpose of this study was to determine if a resuscitation course taught in a spaced format compared to the usual massed instruction results in improved retention of procedural skills. Methods: EMS providers (Paramedics and Emergency Medical Technicians (EMT)) were block randomized to receive a Pediatric Advanced Life Support (PALS) course in either a spaced format (four 210-minute weekly sessions) or a massed format (two sequential 7-hour days). Blinded observers used expert-developed 4-point global rating scales to assess video recordings of each learner performing various resuscitation skills before, after and 3-months following course completion. Primary outcomes were performance on infant bag-valve-mask ventilation (BVMV), intraosseous (IO) insertion, infant intubation, infant and adult chest compressions. Results: Forty-eight of 50 participants completed the study protocol (26 spaced and 22 massed). There was no significant difference between the two groups on testing before and immediately after the course. 3-months following course completion participants in the spaced cohort scored higher overall for BVMV (2.2 ± 0.13 versus 1.8 ± 0.14, p = 0.012) without statistically significant difference in scores for IO insertion (3.0 ± 0.13 versus 2.7 ± 0.13, p = 0.052), intubation (2.7 ± 0.13 versus 2.5 ...