Immersive Simulation Experience Research Articles

Virtual reality as an engaging and enjoyable method for delivering emergency clinical simulation training: a prospective, interventional study of medical undergraduates

BackgroundIt is a requirement that medical students are educated in emergencies and feel well prepared for practice as a doctor, yet national surveys show that many students feel underprepared. Virtual reality (VR), combined with 360-degree filming, provides an immersive, realistic, and interactive simulation experience. Unlike conventional in-person simulation, it is scalable with reduced workforce demands. We sought to compare students’ engagement and enjoyment of VR simulation to desktop computer-based simulation.MethodsWe conducted a prospective, interventional, evaluation study. The study was carried out on final year medical students undertaking their Pre-Foundation Assistantship (n = 116) at Imperial College School of Medicine (ICSM) in London. We compared objective engagement, subjective engagement, and subjective enjoyment of VR simulation to desktop computer-based simulation using cardiac arrest and life-threatening asthma scenarios. Engagement was measured objectively using students’ physiological parameters, including heart rate and eye tracking, and facilitator observations using the validated ‘Behavioural Engagement Related to Instruction’ (BERI) protocol. Students’ subjective engagement and enjoyment levels were measured using a post-session survey.ResultsStudents’ maximum heart rates were significantly higher during VR simulation with a mean difference of 4.2 beats per minute (3.2 to 5.2, p < 0.001), and eye tracking showed they spent a significantly greater mean percentage of time of 6.4% (5.1 to 7.7, p < 0.001) focusing on the scenarios in VR compared to standard desktop. Qualitative data showed students enjoyed and felt engaged with the sessions, which provided a safe space for learning.ConclusionsOur study shows that students found VR simulations enjoyable and were more engaged compared to standard desktop simulation. This suggests that 360-degree VR simulation experiences provide students with immersive, realistic training, which is scalable, giving them the unique opportunity to manage emergencies and work within emergency teams, which would not typically occur during traditional training.

Immersive distance simulation: Exploring the educational impact of stereoscopic extended reality (XR) video in remote learning environments

What was the educational challenge? There is a growing need for healthcare simulation options when local expertise or resources are not available. To connect instructors with remote learners, current options for distance simulation are typically limited to videoconferencing on desktop computers or mobile devices, which may not fully capture the complexity of clinical scenarios. What was the solution? Extended reality (XR) technology may provide a more immersive and realistic distance healthcare simulation experience compared to traditional videoconferencing options. Unlike computer- or phone-based video calls, stereoscopic video in XR provides a sense of depth that may increase spatial understanding and engagement in distance simulation. How was the solution implemented? We investigated the impact of XR for synchronous distance simulation compared to traditional desktop-based videoconferencing in Emergency Medicine (EM) resident training for an obstetrical emergency. A randomized controlled experiment was conducted with half of the residents using XR and half using computers to participate in the simulation. What lessons were learned that are relevant to a wider global audience? There was an unanticipated interaction between postgraduate year and condition such that performance in the XR condition was superior for first year residents, while this was reversed for more experienced residents. This indicates that the benefits of XR might be dependent on participant characteristics, such as learner level. What are the next steps? We plan to extend this research to clarify characteristics of learners and tasks that are important determinants of differences in outcomes between stereoscopic XR versus traditional videoconference displays.

The effectiveness of a virtual reality teaching module on advance care planning and advance decision for medical professionals

BackgroundThe concepts of advance care planning (ACP) and advance decisions/directives (ADs) are widely recognized around the world. The Patient Right to Autonomy Act in Taiwan, the first of its kind in Asia, went into effect in 2019. However, a lack of knowledge and confidence regarding ACP and ADs is a barrier for medical professionals in discussing ACP and ADs with their patients. In addition, in Asian countries, physicians tend to make family-centered decisions, which influence how they can implement ADs.MethodsVirtual reality (VR) is known for its immersive and interactive simulation experience and can upgrade medical education. We developed a VR teaching module to help medical professionals better understand ACP and ADs, with assessment tools integrated into the module. The participants were asked to answer seven knowledge items embedded in the module and fill out the surveys regarding attitudes toward ACP and ADs and confidence in implementing ADs before and after the module. They also reported behaviors related to ADs before and three months after the VR experience.ResultsFrom July 2020 to June 2022, 30 physicians and 59 nurses joined the study, and 78.7% of them had no prior experience in hospice care. After learning from the VR module, all 89 participants were able to answer all seven items correctly. The results showed a slightly more positive attitude toward ACP and ADs (scores: 32.29 ± 3.80 versus 33.06 ± 3.96, p < .05) and more confidence in implementing ADs (scores: 13.96 ± 2.68 versus 16.24 ± 2.67, p < .001) after the VR module. Changes in AD-related behaviors (scores: 11.23 ± 4.01 versus 13.87 ± 4.11, p < .001) were also noted three months after the VR experience.ConclusionsThis study found that medical professionals may have better knowledge of ACP and ADs, slightly improved attitudes toward ACP and ADs, and greater confidence in implementing ADs after experiencing the VR module. Most importantly, the findings suggested that using a VR format may help motivate medical professionals to perform essential behaviors related to ADs, including introducing ADs to their patients and discussing ADs with their own family.

Physics-Based Watercraft Simulator in Virtual Reality

In this paper, watercraft and ship simulation is summarized, and the way that it can be extended through realistic physics is explored. A hydrodynamic, data-driven, immersive watercraft simulation experience is also introduced, using the Unreal Engine to visualize a Landing Craft Utility (LCU) operation and interaction with near-shore waves in virtual reality (VR). The VR application provides navigation scientists with a better understanding of how coastal waves impact landing operations and channel design. FUNWAVE data generated on the supercomputing resources at the U.S. Army Corps of Engineers (USACE) Engineering Research and Development Center (ERDC) are employed, and using these data, a graphical representation of the domain is created, including the vessel model and a customizable VR bridge to control the vessel within the virtual environment. Several dimension reduction methods are being devised to ensure that the FUNWAVE data can inform the model but keep the application running in real time at an acceptable frame rate for the VR headset. By importing millions of data points output from the FUNWAVE version 3.4 software into Unreal Engine, virtual vessels can be affected by physics-driven data.

Observation of behavioural skills by medical simulation facilitators: a cross-sectional analysis of self-reported importance, difficulties, observation strategies and expertise development

BackgroundThe association between team performance and patient care was an immense boost for team-based education in health care. Behavioural skills are an important focus in these sessions, often provided via a mannikin-based immersive simulation experience in a (near) authentic setting. Observation of these skills by the facilitator(s) is paramount for facilitated feedback with the team. Despite the acknowledgement that trained facilitators are important for optimal learning, insight into this observation process by facilitators is limited.ObjectivesWhat are the self-reported current practices and difficulties regarding the observation of behavioural skills amongst facilitators during team training and how have they been trained to observe behavioural skills?MethodsThis cross-sectional study used a pilot-tested, content-validated, multi-linguistic online survey within Europe, distributed through a non-discriminative snowball sampling method. Inclusion was limited to facilitators observing behavioural skills within a medical team setting.ResultsA total of 175 persons filled in the questionnaire. All aspects of behavioural skill were perceived as very important to observe. The self-perceived difficulty of the behavioural skill aspects ranged from slightly to moderately difficult. Qualitative analysis revealed three major themes elaborating on this perceived difficulty: (1) not everything can be observed, (2) not everything is observed and (3) interpretation of observed behavioural skills is difficult. Additionally, the number of team members health care facilitators have to observe, outnumbers their self-reported maximum. Strategies and tools used to facilitate their observation were a blank notepad, co-observers and predefined learning goals. The majority of facilitators acquired observational skills through self-study and personal experience and/or observing peers. Co-observation with either peers or experts was regarded as most learn some for their expertise development. Overall, participants perceived themselves as moderately competent in the observation of behavioural skills during team training.ConclusionsObservation of behavioural skills by facilitators in health care remains a complex and challenging task. Facilitators’ limitations with respect to attention, focus and (in)ability to perform concomitant tasks, need to be acknowledged. Although strategies and tools can help to facilitate the observation process, they all have their limitations and are used in different ways.

Dementia Simulation Impact on Empathy of Nursing and Physical Therapy Students: A Quantitative Study

BackgroundAs the population ages, the incidence of Alzheimer's disease and related dementias (ADRD) increases. Health care students participated in a simulated dementia experience to increase their understanding of the lived reality of people diagnosed with ADRD. A foundation for therapeutic relationships is understanding which incorporates empathy. Health care professionals possessing empathy have demonstrated improved patient satisfaction. MethodsThis quantitative study used Kolb's experiential learning theory as a foundation for assessing empathy of health care students using a pre- postsurvey design. Health care students included 248 baccalaureate nursing students and doctor of physical therapy students. Empathy was measured by the Interpersonal Reactivity Index, perspective taking (PT), and empathic concerns (EC) subscales. ResultsThis study found a statistically significant increase in overall empathy postsimulation measured by the combined PT and EC subscales. The PT subscale also had a statistically significant increase indicating that students increased in the cognitive dimension of empathy post simulated dementia experience. There was no statistically significant change in the EC subscale or affective dimension of empathy post experience. ConclusionsThe immersive simulation experience increased the cognitive dimension of empathy in nursing and physical therapy students.

The experiencing sensory overload project (ESOP): developing an immersive simulation experience for healthcare professionals.

Atypical sensory processing is described as a difficulty in regulating and managing sensory input in a meaningful, ordered way to make sense of the world and environment in which you find yourself. Sensory processing disorder (SPD) is common in individuals with autism, pervasive development disorders, and neurodivergent conditions [1,2,3]. The National Institute of Clinical Excellence (NICE) [2] suggest sensory processing disorders are often overlooked by education, social, and healthcare professionals, leading to health and social inequalities with individuals less able to access ‘support and services that they need to live independently’ [2 p5]. The Experiencing Sensory Overload Project (ESOP) aims to champion inclusive practice and reduce health inequalities by encouraging and enabling healthcare professionals to reconsider their approach, and their working environments to create sensorily safe spaces for individuals who may experience sensory overload. The authors recognised there was insufficient education on SPD within the current nursing curriculum. To address this theory/practice gap, training was sought externally. This consisted of a short simulation-based activity with training delivered by carers who had experience of sensory overload. This was well evaluated by the student participants; however lecturing staff felt the training did not meet our university teaching and learning standards. The positive student feedback provided the impetus to forge links with digital arts colleagues to co-create a robust, pedagogically sound and immersive learning experience. The collaborative journey of ESOP has been led and facilitated by academics from the School of Nursing and Midwifery and the School of Arts in a cross-school alliance ( Immersive learning experiences that recognise and champion diversity must be integrated into the curricular of all healthcare professionals to promote the highest standards of patient care. Meeting this demand with innovative, immersive technology demands collaborative working. This cross-school alliance has produced a learning experience that can work towards reducing health inequalities, promoting independence, and championing inclusive practice. The experiencing sensory overload project (ESOP) collaborative journey 2019–2022 1. Walbam KM. The relevance of sensory processing disorder to social work practice: An interdisciplinary approach. Child and Adolescent Social Work Journal. 2014;31(1):61–70. 2. National institute Clinical Excellence. Autism spectrum disorder in adults: diagnosis and management. London: NICE; 2012. 1–42. CG142 3. Bolaños C, Gomez MM, Ramos G, Rios del Rio J. Developmental risk signals as a screening tool for early identification of sensory processing disorders. Occupational therapy international. 2016;23(2):154–164.

Meaningful simulation: service user and academic collaboration supporting physiotherapy students with healthy conversations

Lifestyle factors are a significant cause of mortality and morbidity in England [1]. Physiotherapists are well placed to help people to make healthy lifestyle choices, however junior physiotherapists do not feel well equipped to have these conversations [2]. An innovative teaching session was carried out with physiotherapy students to 1) increase their confidence in addressing lifestyle choices and 2) equip them with communication skills to decrease fear of these difficult conversations. The session was grounded in the theory of motivational interviewing [3]. Teaching staff created role play scenarios. These were reviewed by service users for authenticity. The scenarios included a teenager with cystic fibrosis who was not compliant with chest clearance exercises and a person suffering falls secondary to alcohol misuse. The final scenario involved a discussion about smoking with a person recently diagnosed with a chronic lung condition and their partner. In a face-to-face immersive fishbowl setting, students took part in the scenarios with experienced actors as service users. The session was collaborative, where students could ‘time out’ to seek guidance from their peers. The actors adapted their communication depending on how they felt in the conversation. After each scenario the actors provided feedback from the service user perspective. There was excellent engagement in the session. Students found the final scenario the most challenging as they struggled to gain a rapport with the patient actor due to the partner frequently interrupting. The cohort expressed different ideas of how to manage this situation. Feedback from the actors helped the students to consider the perspective of the partner and how their interference was due to worry. Pre- and post-session data on a five-point Likert scale demonstrated improved knowledge of motivational interviewing and improved confidence to have lifestyle change conversations ( Likert scores to the pre- and post-motivational interviewing simulation training The immersive simulation experience motivated and empowered the physiotherapy students to talk about lifestyle change with service users. The participative forum felt ‘real’ and students left the session better equipped to have lifestyle change conversations with service users. This should help to create future physiotherapists who can help people to live healthy lives. 1. Office for National Statistics. What is happening to life expectancy in England? England: The King’s Fund; 2022. 2. Walkenden S, Walker KM. Perceptions of physiotherapists about their role in health promotion at an acute hospital: a qualitative study. Physiotherapy. 2015;101(2):226–231 3. Rollnick S, Miller WR, Butler CC. Motivational Interviewing in Health Care. London: The Guildford Press, 2008.

Face-to-Face and Online Interprofessional Immersive Experiences: A Qualitative Study

At the study site for this research, Interprofessional Education taught in distance learning courses can be challenging for faculty, impacting student engagement, motivation, and success. A qualitative case study was conducted with students to explore participant perceptions of their engagement following their participation in a virtual synchronous immersive experience. The study took place during four consecutive semesters beginning in the Spring 2019 term. Participants at the study site are learning in a healthcare strategic planning course class that focuses on interprofessional collaboration as a basis of health strategy. Data was collected using open-ended questionnaires to determine students’ online versus face-to-face immersive learning experiences. Findings suggest that due to their engagement experiences, participation in a virtual Immersive Learning Simulation experience may be a viable substitute for the traditional face-to-face learning experiences. After the Immersive Learning experience, participating students and the healthcare experts were asked to respond to a questionnaire to assess their perceptions of the strengths, weaknesses, and opportunities offered by the online immersive event. This research study offers new information about students’ and healthcare experts’ perceptions of an online immersive IPE experience while identifying possible strengths, weaknesses, and opportunities.

205 Simulation as a form of Immersive Theatre

Immersive theatre is a style of theatre that removes the fourth wall of traditional theatre turning the audience into participants and engaging the five senses such as sight, sound, touch, taste and smell; a concept applied equally to multi-professional, human factor-based simulation. Peter Brook, one of our greatest theatre directors, says, ‘Drama is exposure; it is confrontation; it is a contradiction, and it leads to analysis, construction, recognition and eventually to an awakening of understanding’. This is without doubt what we do in simulation. We create scenarios, ‘the drama’, we create managing deteriorating patients, the ‘confrontation and contradiction’ and we enter debriefing, the ‘analysis, construction and eventual awakening of understanding’. Using the concepts of immersive theatre and drama, creating more realistic environments and authentic interactions, we can offer the participants a greater sense of reality in which to practice vital inter-professional medical care. High-fidelity simulation encompasses more than just a technological top of the range manikin which often comes at a premium cost. High-fidelity simulation is an attack on all of the senses, visually sick patients, noises and smells of the environment, even touch and taste. The soundscape of an emergency room, smells of humans, drugs, equipment, tastes of stewed tea and warm water, the touch of a sick patient or a disruptive relative in a visually authentic space creates the perfect setting for an immersive simulation experience. By implementing psychological, sociological and physical fidelity, we offer a unique way of practicing essential skills of interprofessional working not only to enhance patient care and safety but also to allow a greater understanding of ourselves and others in stressful, urgent and critical situations. Applying ideas from the world of drama and theatre, creating authentic immersive environments can give participants the freedom to be in the simulation and steer them away from acting in the simulation.

Findings from a mixed-methods pragmatic cluster trial evaluating the impact of ethics education interventions on residential care-givers.

There has been little previous research regarding the effectiveness of ethics education interventions for residential care-givers. The Researching Interventions to Promote Ethics in social care project responded to the question: Which is the most effective ethics education intervention for care-givers in residential social care? A pragmatic cluster trial explored the impact of three ethics education interventions for: (a) interactive face-to-face ethics teaching; (b) reflective ethics discussion groups; and (c) an immersive simulation experience. There was also a control arm (d). 144 trial participants were recruited from 39 residential care homes for older people in southern England. Change scores compared across intervention arms showed a significant reduction in work-related moral stress in the teaching arm compared with control group (p=.03); there were no significant differences between control and intervention arms in change scores for moral sensitivity, interpersonal reactivity (empathy) or ethical leadership. Qualitative data themes were as follows: ethical care; care challenges; and ethical care inhibitors. Overall findings stimulate reflection on the value of three different ethics education interventions and the most appropriate means to evaluate their impact. Findings suggest the complexity and diverse nature of ethical competence in care. We suggest a way forward for research evaluating ethics education.

An Immersive Simulation to Build Empathy for Geriatric Patients with Co-Occurring Physical and Mental Illness.

The objective of the study was to explore the effectiveness of an immersive simulation experience using an aging simulation suit for fostering empathy towards geriatric patients with advanced mental illness. Psychiatry residents were recruited during their clinical rotations at a Canadian mental health hospital. The participants took on the first-person perspective of a geriatric patient with mental illness initially through written reflection, and then physically inhabited this role by wearing an aging simulation suit to perform the task of meeting with a pharmacist to review current medications and prepare a dosette. Concurrently, an audio file was played through headphones to simulate auditory hallucinations. A pre- and post-Jefferson Scale of Empathy (JSE), reflective writing exercise, debrief transcription, and evaluation questionnaire were used to evaluate the intervention. Interviews conducted 3month post-intervention explored its impact on their clinical practice. Fifteen psychiatry residents completed the study. There was a significant increase in JSE scores pre (M = 115.5, SD = 13.2) to post (M = 119.2, SD = 12.7) intervention, t(14) = 2.65, p = .02. The qualitative findings of the study demonstrated participants' improved understanding and awareness of the patient perspective and the ability to communicate this understanding and show intentions to help through practice change. An aging suit simulation with debriefing may be an effective educational intervention to incorporate into the medical curriculum to foster empathy for this stigmatized population.

A Teaching Innovation on Poverty for Interprofessional Students: Cost of Poverty Experience Simulation

INTRODUCTION Cost of Poverty Experience (COPE) simulation is an innovative teaching methodology to demonstrate the obstacles and challenges of poverty that contribute to those risks. The aim of the study was to evaluate the change in attitudes regarding people living in poverty among interprofessional health science students. METHODS Medicine, nursing, pharmacy and rehabilitation therapy students in the 2018 Interprofessional Education class (N=100) were enrolled. Interprofessional student teams were assigned family roles, given limited resources and simulated poverty challenges such as unemployment, childcare concerns, limited access to healthy food, and incarceration. A pre- and post-simulation survey measured changes in participants’ poverty awareness consisting of three domains - identifying barriers to poverty, confidence in one’s ability to address poverty, and likelihood to engage in behaviors to address poverty. The post survey also included questions on insights gained and recognition of organizational systems that perpetuate poverty. Statistical analysis including descriptive statistics and paired t-tests were conducted in SPSS-v23. RESULTS The confidence in ability domain that included understanding obstacles, identifying key issues and having impact showed a significant difference between pre-test (M=8.63, SD= 1.71) and post-test (M=9.31, SD=1.90). However, no significant change was reported for identifying barriers and likelihood to engage in behaviors to address poverty. Additionally, in post-survey, more than 90% students reported increased mindfulness of poverty, self-reflection, and recognize that organizational systems create and perpetuate poverty. CONCLUSION Poverty immersive simulation experience is an essential education tool, as it motivates critical selfreflection and improves one’s confidence to engage in addressing poverty.

Development of a phenomenologically derived method to assess affective learning in student journals following impactive educational experiences

Background: Assessment of affective learning (AL) is difficult but important, particularly for health professional students, where it is intimately linked to the development of professional values. This study originally aimed to determine whether an emotionally impactive, extended, multimethod, interprofessional simulation experience enhanced the AL of senior medical students, compared to conventional seminars and workshops alone. This necessitated the development of a method to assess for the presence and quality of AL.Methods: We developed a “double hermeneutic” method, derived from Smith’s Interpretative Phenomenological Analysis, to identify examples of AL, according to Krathwohl’s hierarchy (“receiving,” “responding,” “valuing,” “organization,” “characterization”), in the journals of students from each arm of a randomized educational trial. Three assessors rated the highest level of AL seen in each journal and then we compared ratings from the two study arms.Results: A total of 135 journals were available for assessment (81 Intervention, 54 Control). The method proved to be effective in identifying and characterizing examples of uniprofessional and interprofessional AL. The median level identified in Intervention journals (“valuing”) was significantly higher than Control journals (“responding,” p < 0.0001).Conclusions: The method described provides a means to assess affective learning among health professional students. An extended, immersive simulation experience appears to enhance affective learning.

Investigating the Use and Design of Immersive Simulation to Improve Self-Efficacy for Aspiring Principals

Aim/Purpose: Improving public schools is a focus of federal legislation in the United States with much of the burden placed on principals. However, preparing principals for this task has proven elusive despite many changes in programming by institutions of higher learning. Emerging technologies that rely on augmented and virtual realities are posited to be powerful pedagogical tools for closing this gap. Background: This study investigated the effects of immersive simulation technologies on principals’ self-efficacy after treatment and the perceived significance of the design of the immersive simulation experience as an effective tool for adult learners. Methodology: The investigator employed a multiple-methods study that relied on a purposive sample of graduate students enrolled in educational leadership programs at two small universities in the southeastern United States. Participants completed a two-hour module of immersive simulation designed to facilitate transfer of knowledge to skills thereby increasing their self-efficacy. Contribution: This paper contributes to a small body of literature that examines the use of immersive simulation to prepare aspiring principals. Findings: The findings indicate moderate effect sizes in changes in self-efficacy, positive attitudes toward immersive simulation as a pedagogical tool, and significance in the design of immersive simulation modules. This suggests that immersive simulation, when properly designed, aids principals in taking action to improve schools. Recommendations for Practitioners: Educational leadership programs might consider the use of immersive simulations to enhance principals’ ability to meet the complex demands of leading in the 21st century. Impact on Society: Principals may be more adept at improving schools if preparation programs provided consistent opportunities to engage in immersive simulations. Future Research: Future research should be conducted with larger sample sizes and longitudinally to determine the effectiveness of this treatment.

Care-givers' reflections on an ethics education immersive simulation care experience: A series of epiphanous events.

There has been little previous scholarship regarding the aims, options and impact of ethics education on residential care-givers. This manuscript details findings from a pragmatic cluster trial evaluating the impact of three different approaches to ethics education. The focus of the article is on one of the interventions, an immersive simulation experience. The simulation experience required residential care-givers to assume the profile of elderly care-recipients for a 24-hr period. The care-givers were student nurses. The project was reviewed favourably by a university ethics committee, and participants provided informed consent. Data from six postsimulation experience focus groups were analysed thematically and three themes were identified: the experience of vulnerability, dignity in care and the organisation of care. Findings suggest that the immersive simulation experience had a powerful immediate impact as participants described epiphanous insights relating to their care experiences. It is suggested that reflecting on and recording epiphanous events has the potential to sustain ethical care practices. Further research is required to evaluate the impact of different ethics education interventions in different cultural contexts. Exploration is also required regarding the meaning and significance of care epiphanies, those "most delicate and evanescent of moments," for the sustainability of ethical care.

Looking for zebras and finding horses: A qualitative narrative study of pre-RN licensure nursing Students' experience of a “normal” postnatal simulation

BackgroundSimulation-based learning may be particularly useful in specialty nursing clinical rotations, such as maternal-newborn care, where pre-RN licensure nursing students typically have fewer clinical hours or ‘hands-on’ opportunities. Although simulated obstetric emergencies are frequently reported in the literature, childbirth and the postnatal period involve normal physiologic processes, and therefore a focus on “normal” challenges in immersive perinatal simulations may provide students with vital uniform clinical learning experiences. ObjectiveTo explore the value and meaning of an uncomplicated immersive postnatal simulation-based experience for pre-RN licensure nursing students. DesignQualitative design using narrative analysis. SettingPre-RN licensure nursing program at a university in the northeastern United States. MethodsNarrative analysis was used to assess 229 written reflections from students following an uncomplicated, immersive postnatal simulation experience. ResultsThemes identified through the analysis demonstrated that students experienced high anxiety in anticipation of the scenario, expecting a crisis to occur; students described looking for zebras as they searched for pathology but found “normality”. Students derived confidence from performing assessments and making clinical decisions, moving from anxiety to relief as they concluded that the mother and infant were experiencing normal, rather than emergent, challenges of the postnatal period. ConclusionMost students found value in the experience, recognizing the importance of learning maternal-newborn nursing from a physiologic rather than pathologic perspective.

Transfusion Ethics in a Pediatric Jehovah's Witness Trauma Patient: Simulation Case.

Current ethical practice allows for adult patients with decision-making capacity to refuse blood transfusion, even at the cost of high morbidity or mortality. However, for an adult patient who is of the Jehovah's Witness faith, an unwanted blood transfusion confers a psychospiritual cost to the patient and a financial cost to health care entities. The ethical boundaries are increasingly ambiguous with minors who are members of the Jehovah's Witness faith. This simulation experience intends to identify and address knowledge gaps in the care of minors in an emergent setting using a biomedical ethics framework. This scenario provides an immersive simulation experience involving a 12-year-old Jehovah's Witness patient requiring emergent laparotomy for splenic hemorrhage. Patient interview (via simulation manikin with instructor voice) and care handoff take place in an operating room setting. The learner ascertains the patient's and family's refusal of blood products. Induction of general anesthesia results in profound patient hypotension secondary to acute blood-loss anemia. Pulseless electrical activity results if packed red blood cells are not administered. Ethical principles require the learner to impose an unwanted lifesaving therapy on a minor patient over the objections of family members. Secondly, the anesthesia provider must advocate for transfusion on these ethical grounds against a well-meaning but ultimately misguided surgeon who opposes transfusion. An included learner evaluation form based on ACGME core competencies facilitates postsimulation debriefing. Participants were primarily anesthesia residents and fellows. Anecdotally, the residents said that it "felt good to be an attending" and that the simulation helped them appreciate how important conflict resolution skills are in the OR setting. Additionally, faculty appreciated the ability to assess the development of crucial assertiveness skills, with the option of remediating incorrect behavior during the debriefing. This simulation experience provides experience in the emergent medical management of a pediatric trauma patient while also incorporating specific ethical consent issues unique to pediatric and trauma patient populations. Furthermore, this experience develops professionalism skills and practice in assertive patient advocacy.

Towards the Next Frontier for Simulation-Based Training

To evaluate the efficacy of an entire hospital simulation in imparting skills to expert healthcare providers, encompassing both retention and transfer to clinical practice. Studies demonstrating the effectiveness of simulation do not concentrate upon expert multidisciplinary teams. Moreover, their focus is confined to a single clinical setting, thereby not considering the complex interactions across multiple hospital departments. A total of 288 participants (Attending surgeons, anesthesiologists, physicians, and nurses) completed this largest simulation study to date, set in the UK Defence Medical Services' Hospital Simulator and the conflict zone in Afghanistan. The simulator termed "Hospital Exercise" (HOSPEX) is a fully immersive live-in simulation experience that covers the entire environment of a military hospital with all departments. Participants undertook a 3-day training program within HOSPEX before deployment to war zones. Primary outcome measures were assessed with IMPAcT (the Imperial Military Personnel Assessment Tool). IMPAcT measures crisis management, trauma care, hospital environment, operational readiness, and transfer of skills to civilian practice. Reliability, skills learning, and retention in the conflict zone were assessed statistically. Reliability in skills assessment was excellent (Cronbach α: nontechnical skills = 0.87-0.94; environment/patient skills = 0.83-0.95). Pre/post-HOSPEX comparisons revealed significant improvements in decision making (M = 4.98, SD = 1.20 to M = 5.39, SD = 0.91; P = 0.03), situational awareness (M = 5.44, SD = 1.04 to M = 5.74, SD = 0.92; P = 0.01), trauma care (M = 5.53, SD = 1.23 to M = 5.85, SD = 1.09; P = 0.05), and knowledge of hospital environment (M = 5.19, SD = 1.17 to M = 5.42, SD = 0.97; P = 0.04). No skills decayed over time when assessed several months later in the real conflict zone. All skills transferred to civilian clinical practice. This is the first study to describe the value of a full-hospital simulation across the entire patient pathway. Such macrosimulations may be the way forward for integrating the complex training needs of expert clinicians and testing organizational "fitness for purpose" of entire hospitals.

Proposing “The Burns Suite” as a Novel Simulation Tool for Advancing the Delivery of Burns Education

Educational theory highlights the importance of contextualized simulation for effective learning. We explored this concept in a burns scenario in a novel, low-cost, high-fidelity, portable, immersive simulation environment (referred to as distributed simulation). This contextualized simulation/distributed simulation combination was named "The Burns Suite" (TBS). A pediatric burn resuscitation scenario was selected after high trainee demand. It was designed on Advanced Trauma and Life Support and Emergency Management of Severe Burns principles and refined using expert opinion through cognitive task analysis. TBS contained "realism" props, briefed nurses, and a simulated patient. Novices and experts were recruited. Five-point Likert-type questionnaires were developed for face and content validity. Cronbach's α was calculated for scale reliability. Semistructured interviews captured responses for qualitative thematic analysis allowing for data triangulation. Twelve participants completed TBS scenario. Mean face and content validity ratings were high (4.6 and 4.5, respectively; range, 4-5). The internal consistency of questions was high. Qualitative data analysis revealed that participants felt 1) the experience was "real" and they were "able to behave as if in a real resuscitation environment," and 2) TBS "addressed what Advanced Trauma and Life Support and Emergency Management of Severe Burns didn't" (including the efficacy of incorporating nontechnical skills). TBS provides a novel, effective simulation tool to significantly advance the delivery of burns education. Recreating clinical challenge is crucial to optimize simulation training. This low-cost approach also has major implications for surgical education, particularly during increasing financial austerity. Alternative scenarios and/or procedures can be recreated within TBS, providing a diverse educational immersive simulation experience.