Immersive Training Research Articles

VR Presentation Training System Using Machine Learning Techniques for Automatic Evaluation

In this paper, the authors build an immersive training space using building-scale VR, a technology that makes a virtual space based on an entire building existing in the real world. The space is used for presentations, allowing students to self-train. The results of a presentation are automatically evaluated by using machine learning or the like and fed back to the user. In this space, users can meet their past selves (more accurately, their avatars), so they can objectively observe their presentations and recognize weak points. The authors developed a mechanism for recording and reproducing activities in virtual space in detail and a mechanism for applying machine learning to activity records. With these mechanisms, a system for recording, reproducing, and automatically evaluating presentations was developed.

1306 Recommendations for the Use of Simulators in Cardiothoracic Surgical Training

Abstract Aim To systematically review the simulators that are currently available for cardiothoracic surgical procedures and the validation evidence supporting them. Additionally, to recommend several simulators for training based on analysis of results. Method A systematic literature search of the MEDLINE® (1946 to December 2019) and EMBASE® (1947 to December 2019) databases was performed to identify simulators for basic skills and procedures in cardiothoracic surgery. A selection of keywords and MeSH terms were used to execute the literature search. After identification of relevant articles, data were extracted and analysed. Results Ninety simulators were found in eighty-one articles. Simulators for basic skills (n=24) and coronary artery bypass graft (n=22) were the most commonly described, followed by miscellaneous (n=14), valve surgery (n=13), thoracic lobectomy (n=10), and mechanical circulatory support (n=7). The majority of models were either benchtop (n=42) or hybrid (n=33) modalities. Evidence of validity was demonstrated in 38 (42.2%) simulators. Five (5.6%) simulators had three or more elements of validity established and only one (1.1%) accomplished full validation. Conclusions Five simulators were recommended for supplemental training in cardiothoracic surgery. Low-fidelity models can provide a broad foundation for surgical skills development and high-fidelity simulators can be used for immersive training scenarios and appraisals. These should be utilised in early training, at which point the learning curve of trainees is steepest.

Effect of an Immersive Primary Care Training Program on Educational and Clinical Outcomes in an Internal Medicine Residency Training Program: Meeting the Training Needs of a Modern-Day Physician Workforce.

Residents planning careers in primary care have unique training needs that are not addressed in traditional internal medicine training programs, where there is a focus on inpatient training. There are no evidence-based approaches for primary care training. Design and test the effect of a novel immersive primary care training program on educational and clinical outcomes. Nested intervention study. Twelve primary care residents, 86 of their categorical peers, and an 11-year historical cohort of 69 primary care trainees in a large urban internal medicine residency training program. Two 6-month blocks of primary care immersion alternating with two 6-month blocks of standard residency training during the second and third post-graduate years. Total amount of ambulatory and inpatient training time, subjective and objective educational outcomes, clinical performance on cancer screening, and chronic disease management outcomes. Participants in the intervention increased ambulatory training in both general medicine and specialty medicine and still met all ACGME training requirements. Residents reported improved subjective educational outcomes on a variety of chronic disease management topics and ambulatory care skills. They reported higher satisfaction with the amount of ambulatory training (4.3/5 vs. 3.6/5, p=0.008), attended more ambulatory clinics (242 vs. 154, p<0.001), and carried larger, more complicated panels (173 vs. 90 patients, p<0.001). They also performed better on diabetes management (86% vs. 76% control, p<0.001). Alumni who completed the intervention reported higher primary care career preparation (79% response rate) than those who did not (85% response rate) among an 11-year cohort of primary care alumni (4/5 vs. 3/5, p<0.001). A primary care training program that provides clinical immersion in the ambulatory setting improved educational outcomes for trainees and clinical outcomes for their patients. Providing more training in the ambulatory environment should be a priority in graduate medical education.

Effectiveness and Utility of Virtual Reality Simulation as an Educational Tool for Safe Performance of COVID-19 Diagnostics: Prospective, Randomized Pilot Trial.

BackgroundAlthough the proper use of hygiene and personal protective equipment (PPE) is paramount for preventing the spread of diseases such as COVID-19, health care personnel have been shown to use incorrect techniques for donning/doffing of PPE and hand hygiene, leading to a large number of infections among health professionals. Education and training are difficult owing to the social distancing restrictions in place, shortages of PPE and testing material, and lack of evidence on optimal training. Virtual reality (VR) simulation can offer a multisensory, 3-D, fully immersive, and safe training opportunity that addresses these obstacles.ObjectiveThe aim of this study is to explore the short- and long-term effectiveness of a fully immersive VR simulation versus a traditional learning method regarding a COVID-19–related skill set and media-specific variables influencing training outcomes.MethodsThis was a prospective, randomized controlled pilot study on medical students (N=29; intervention VR training, n=15, vs control video-based instruction, n=14) to compare the performance of hand disinfection, nasopharyngeal swab taking, and donning/doffing of PPE before and after training and 1 month later as well as variables of media use.ResultsBoth groups performed significantly better after training, with the effect sustained over one month. After training, the VR group performed significantly better in taking a nasopharyngeal swab, scoring a median of 14 out of 17 points (IQR 13-15) versus 12 out of 17 points (IQR 11-14) in the control group, P=.03. With good immersion and tolerability of the VR simulation, satisfaction was significantly higher in the VR group compared to the control group (median score of User Satisfaction Evaluation Questionnaire 27/30, IQR 23-28, vs 22/30, IQR 20-24, in the control group; P=.01).ConclusionsVR simulation was at least as effective as traditional learning methods in training medical students while providing benefits regarding user satisfaction. These results add to the growing body of evidence that VR is a useful tool for acquiring simple and complex clinical skills.

Training birdsong recognition using virtual reality

BackgroundIn mega-biodiverse environments, where different species are more likely to be heard than seen, species monitoring is generally performed using bioacoustics methodologies. Furthermore, since bird vocalizations are reasonable estimators of biodiversity, their monitoring is of great importance in the formulation of conservation policies. However, birdsong recognition is an arduous task that requires dedicated training in order to achieve mastery, which is costly in terms of time and money due to the lack of accessibility of relevant information in field trips or even specialized databases. Immersive technology based on virtual reality (VR) and spatial audio may improve species monitoring by enhancing information accessibility, interaction, and user engagement. MethodsThis study used spatial audio, a Bluetooth controller, and a head-mounted display (HMD) to conduct an immersive training experience in VR. Participants moved inside a virtual world using a Bluetooth controller, while their task was to recognize targeted birdsongs. We measured the accuracy of recognition and user engagement according to the User Engagement Scale. ResultsThe experimental results revealed significantly higher engagement and accuracy for participants in the VR-based training system than in a traditional computer-based training system. All four dimensions of the user engagement scale received high ratings from the participants, suggesting that VR-based training provides a motivating and attractive environment for learning demanding tasks through appropriate design, exploiting the sensory system, and virtual reality interactivity. ConclusionsThe accuracy and engagement of the VR-based training system were significantly high when tested against traditional training. Future research will focus on developing a variety of realistic ecosystems and their associated birds to increase the information on newer bird species within the training system. Finally, the proposed VR-based training system must be tested with additional participants and for a longer duration to measure information recall and recognition mastery among users.

A Review of Human Circulatory System Simulation: Bridging the Gap between Engineering and Medicine.

(1) Background: Simulation-based training (SBT) is the practice of using hands-on training to immerse learners in a risk-free and high-fidelity environment. SBT is used in various fields due to its risk-free benefits from a safety and an economic perspective. In addition, SBT provides immersive training unmatched by traditional teaching the interactive visualization needed in particular scenarios. Medical SBT is a prevalent practice as it allows for a platform for learners to learn in a risk-free and cost-effective environment, especially in critical care, as mistakes could easily cause fatalities. An essential category of care is human circulatory system care (HCSC), which includes essential-to-simulate complications such as cardiac arrest. (2) Methods: In this paper, a deeper look onto existing human circulatory system medical SBT is presented to assess and highlight the important features that should be present with a focus on extracorporeal membrane oxygenation cannulation (ECMO) simulators and cardiac catheterization. (3) Results: A list of features is also suggested for an ideal simulator to bridge the gap between medical studies and simulator engineering, followed by a case study of an ECMO SBT system design. (4) Conclusions: a collection and discussion of existing work for HCSC SBT are portrayed as a guide for researchers and practitioners to compare existing SBT and recreating them effectively.

Description of a Human-Centered Design Approach to Develop Novel Virtual Reality Applications to Improve Functional Outcomes Following Brain Injury

<h3>Research Objectives</h3> Brain injury continues to be a leading cause of serious long-term disability. The objective of this project is to develop and implement innovative assessment and intervention strategies, via robotics and virtual reality systems, to improve balance and walking capabilities for persons with neurologic conditions. <h3>Design</h3> A Human-centered design (HCD) framework is being used to guide the development process and to ensure its end products are usable and useful. HCD develops solutions by involving the stakeholder perspective in all steps of the problem solving process - which includes brainstorming, conceptualizing, developing, and implementing the solution. <h3>Setting</h3> Remote collaboration between a Neuro-recovery Center and an independent virtual reality (VR) and robotics laboratory (Immersive Experience Laboratories LLC (IXL)). <h3>Participants</h3> Physical Therapists, Occupational Therapists, persons with traumatic brain injury, and VR application hardware and software developers. <h3>Interventions</h3> Not Applicable. <h3>Main Outcome Measures</h3> Description of the development process of a clinician-designed virtual reality (VR) application for deployment with individuals recovering from brain injury; time to initial uptake of technology; patient and clinician preferences; and clinical outcome scores. <h3>Results</h3> Focus group meetings with clinicians have revealed needs that have strong potential to be effectively addressed by immersive and interactive virtual-reality (VR) interventions, including Identification of Hazards, Care of Others, Garage Time, and Guided Walking. Development of functional platforms for immersive VR training and asset development of indoor household settings is principally complete. Development of treadmill-integrated gait-management platform is principally complete. We currently continue iterative development of content with biweekly feedback from subject-matter-expert clinicians. <h3>Conclusions</h3> The HCD framework could be readily adaptable to other rehabilitation centers interested in developing and implementing these kinds of technologies for the patients they serve. <h3>Author(s) Disclosures</h3> No conflicts of interest

The Next Step: The California Cybersecurity Institute’s Anti-Trafficking Virtual Reality Immersion Training

Digital gaming and virtual learning platforms have expanded the boundaries of experiential based anti-trafficking training. Virtual reality provides a technological mechanism for immersive storytelling through the simulation of a physical presence within an artefact using software and specialised hardware. The success of virtual-based immersive training is directly dependent on a series of factors, including realism, re-playability, and supplemental in-person training. This article describes the California Cybersecurity Institute’s anti-trafficking immersion training programme, which advances beyond awareness education to test law enforcement and first responder-specific skills and biases. This multi-layered programme looks to incorporate all concepts of ‘serious gaming’ within law enforcement and humanitarian communication.

Exploring transformative learning for trainee pharmacists through interprofessional simulation: a constructivist interview study

BackgroundThe expanding roles of UK pharmacists have prompted substantial changes to the initial pharmacy education and training, including increasing recognition of the value of learning alongside other professional groups in acute settings. Interprofessional immersive simulation training appears to represent a useful educational tool to meet the evolving needs of the profession, but the impact of such training on workplace behaviour and relationships has not been explored. This study aimed to explore how interprofessional simulation training facilitates transformative learning in pre-registration pharmacists.MethodsAcross three different locations in Scotland, pre-registration pharmacists were paired with medical students to participate in immersive simulation scenarios with post-scenario debriefs. Pre-registration pharmacists were individually interviewed shortly after their simulation session, using a semi-structured interview schedule based on the transformative learning framework. Transcripts were analysed using template analysis, with Mezirow’s phases of perspective transformation forming the initial coding template.ResultsFifteen interviews following five simulation sessions at three different sites were undertaken. Phases 1–6 of the transformative learning framework all resonated with the pre-registration pharmacists to varying degrees. Two prominent threads became evident in the data: a change in participants’ perceptions of risk, and deepened understanding of their role within an acute context. These themes were woven throughout phases 2–6 of the transformative learning framework.ConclusionsInterprofessional immersive simulation training involving acute clinical scenarios has been found to be helpful for pre-registration pharmacists and can foster transformative learning. Through this powerful process, they developed new ways to see the world, themselves and their professional relationships. Positive future actions and roles were planned. As the patient-facing roles of pharmacists expand, educational practices that translate into meaningful change to workplace behaviour and relationships become increasingly important. Carefully constructed interprofessional immersive simulation training should be utilised within pharmacy education more widely.

Employing a User-Centered Approach for Evaluating a VR-based Pilot Training System

Researchers took a user-centered approach to evaluate pilots’ preferences and perceptions of training with an innovative VR-based immersive training device (ITD). Over the course of one week, usability and user experience data were gathered from U.S. Air Force instructor pilots (IPs), unqualified instructor pilots (UIs),and student pilots (SP). Coming from various squadrons, these pilots provided feedback regarding their interactions with the ITDs. A think-aloud protocol, observations, and surveys were used to capture participants’ perceptions of the different hardware variants using the following usability metrics: fit and feel, function, and sustained and future use. At this stage of the development, various configurations of the ITDs were evaluated to determine which technological components should be included in the final design. The data presented here focused on one of those components, the aircraft control or center stick. The results for the stick component will be discussed as a use case as it illustrates the user-centered approach and data analysis strategy that captured and identified noteworthy differences in perceived training value.

Differential impacts of natural L2 immersion and intensive classroom L2 training on cognitive control

The relationship between bilingualism and cognitive control has been controversial. We believe that the discrepant findings are likely driven by the complexities of the bilingual experience, which is consistent with the Adaptive Control Hypothesis. The current study investigates whether the natural language immersion experience and the classroom intensive language training experience have differential impacts on cognitive control. Among unbalanced Chinese-English bilingual students, a natural L2 (second language) immersion group, an L2 public speaking training group, and a control bilingual group without immersion or training experience were compared on their cognitive control abilities, with the participants' demographic factors strictly controlled. The results showed that the L2 immersion group and the L2 speaking group had faster speed than the control group in the Flanker task, whereas the L2 immersion group had fewer errors than the other two groups in the Wisconsin Card Sorting Test (WCST). These results generally provide evidence in favour of the Adaptive Control Hypothesis, specifying that natural L2 immersion and L2 public speaking training experiences are distinctively related to cognitive control. The current study is the first of its kind to link specific bilingual experiences (natural L2 immersion vs. intensive L2 public speaking) with different components of cognitive control.

Evaluation and assessment of virtual reality-based simulated training: exploring the human–technology frontier

PurposeAs new technologies such as immersive and augmented platforms emerge, training approaches are also transforming. The virtual reality (VR) platform provides a completely immersive learning experience for simulated training. Despite increased prevalence of these technologies, the extent literature is lagging behind in terms of evaluating and assessing such innovative training models. The purpose of this paper is to address this gap through exploring the traditional approaches of quantitative, qualitative and mixed methods as well as the cutting-edge biometric approach in the evaluation and assessment of the VR-based simulated training and discuss implications for simulated training based on immersive technologies.Design/methodology/approachEvaluation and assessment is one of the most critical components of training and development. Inaccurate or ineffective approaches to evaluate and assess training programs not only risk the successful attainment of training goals and outcomes, but they also harm trainees by misleading them about their training performances and experiences. This paper uses a review of existing literature to explore effective approaches for the evaluation and assessment of VR-based simulated training and conceptually discusses new capacities in capturing involuntary trainee reaction toward stimuli, in addition to traditional evaluation and assessment methods.FindingsImmersive VR-based simulated training is uncharted territory for trainers and human resource development professionals. The findings indicate that existing approaches are still viable options for the evaluation and assessment of this new training technology. However, biometrics presents new frontiers in this arena through its capacity for obtaining trainee emotional responses to stimuli during training, as well as providing a venue free of personal bias and external influences in determining trainee perceptions.Originality/valueThis paper addresses an important gap in the field of training and development by studying the affordances of the latest biometric technology for evaluation and assessment in VR-based simulated training. The existing literature is very limited in its focus on immersive training technologies such as VR in general and evaluation and assessment in particular. The paper presents new insights to both researchers and practitioners in the field of training and development.

Effect of Immersive Virtual Reality-Based Bilateral Arm Training in Patients with Chronic Stroke.

Virtual reality (VR)-based therapies are widely used in stroke rehabilitation. Although various studies have used VR techniques for bilateral upper limb training, most have been only semi-immersive and have only been performed in an artificial environment. This study developed VR content and protocols based on activities of daily living to provide immersive VR-based bilateral arm training (VRBAT) for upper limb rehabilitation in stroke patients. Twelve patients with chronic stroke were randomized to a VRBAT group or a normal bilateral arm training (NBAT) group and attended 30-min training sessions five times a week for four weeks. At the end of the training, there was a significant difference in upper limb function in both groups (p < 0.05) and in the upper limb function sensory test for proprioception in the NBAT group (p < 0.05). There was no significant between-group difference in upper limb muscle activity after training. The relative alpha and beta power values for electroencephalographic measurements were significantly improved in both groups. These findings indicate that both VRBAT and NBAT are effective interventions for improving upper limb function and electroencephalographic activity in patients with chronic stroke.

Recommendations for the use of coronary and valve simulators in cardiac surgical training: a systematic review.

The aim of this study was to systematically review the simulators that are currently available for coronary artery bypass graft and valve surgery and, in addition, to review the validation evidence supporting them and to recommend several simulators for training based on the analysis of results. A systematic literature search of the MEDLINE® (1946 to May 2021) and EMBASE® (1947 to May 2021) databases was performed to identify simulators for coronary artery and valvular procedures in cardiothoracic surgery. A selection of keywords and MeSH terms was used to execute the literature search. After identification of relevant articles, data were extracted and analysed. Thirty-seven simulators were found in 31 articles. Simulators were found for coronary artery bypass graft (n = 24) and valve surgery (n = 13). The majority of models were either benchtop (n = 28) or hybrid (n = 8) modalities. Evidence of validity was demonstrated in 15 (40.5%) simulators. Twenty-two (59.5%) simulators had no validation evidence, and 1 (2.7%) simulator had 3 or more elements of validity established. Two simulators were recommended for supplemental training in cardiothoracic surgery. Low-fidelity models can provide a broad foundation for surgical skills' development whereas high-fidelity simulators can be used for immersive training scenarios and appraisals. These should be utilized in early training, at which point the learning curve of trainees is steepest.

Immersive virtual reality enables technical skill acquisition for scrub nurses in complex revision total knee arthroplasty

IntroductionImmersive Virtual Reality (iVR) is a novel technology which can enhance surgical training in a virtual environment without supervision. However, it is untested for the training to select, assemble and deliver instrumentation in orthopaedic surgery—typically performed by scrub nurses. This study investigates the impact of an iVR curriculum on this facet of the technically demanding revision total knee arthroplasty.Materials and methodsTen scrub nurses completed training in four iVR sessions over a 4-week period. Initially, nurses completed a baseline real-world assessment, performing their role with real equipment in a simulated operation assessment. Each subsequent iVR session involved a guided mode, where the software taught participants the procedural choreography and assembly of instrumentation in a simulated operating room. In the latter three sessions, nurses also undertook an assessment in iVR. Outcome measures were related to procedural sequence, duration of surgery and efficiency of movement. Transfer of skills from iVR to the real world was assessed in a post-training simulated operation assessment. A pre- and post-training questionnaire assessed the participants knowledge, confidence and anxiety.ResultsOperative time reduced by an average of 47% across the 3 unguided sessions (mean 55.5 ± 17.6 min to 29.3 ± 12.1 min, p > 0.001). Assistive prompts reduced by 75% (34.1 ± 16.8 to 8.6 ± 8.8, p < 0.001), dominant hand motion by 28% (881.3 ± 178.5 m to 643.3 ± 119.8 m, p < 0.001) and head motion by 36% (459.9 ± 99.7 m to 292.6 ± 85.3 m, p < 0.001). Real-world skill improved from 11% prior to iVR training to 84% correct post-training. Participants reported increased confidence and reduced anxiety in scrubbing for rTKA procedures (p < 0.001).ConclusionsFor scrub nurses, unfamiliarity with complex surgical procedures or equipment is common. Immersive VR training improved their understanding, technical skills and efficiency. These iVR-learnt skills transferred into the real world.

How rural immersion training influences rural work orientation of medical students: Theory building through realist evaluation

Aim To develop theory about how contexts and mechanisms interact to contribute to openness to future rural practice by medical students undertaking immersive rural training. Methods A realist evaluation based on RAMESES II protocol. We interviewed 23 students exploring Contexts (C) which were external (place-based) and internal (the student’s characteristics), Mechanisms (M) (that drive a response) and Outcomes (O) (openness to rural work). Results ‘Openness to rural work’ related to: a desire to live rurally, work in rural medicine, or consider this as a possibility. This was triggered by responses to experience in rural places of an aspirational, intellectual and emotional nature (mechanisms). Students most affected were those with a strong motivation to help others and who value teamwork. Students with clearly envisaged career paths suited to metropolitan areas, or those retaining/prioritising strong social and community ties in metropolitan areas were less likely to commit to future rural work. Conclusion Our theory indicates multi-level stimuli activates openness. Implications are that rural immersion programs could select students with an orientation towards teamwork, without pre-set professional ideation, and with a strong commitment to helping others. Experiencing rural immersion will trigger aspirational, intellectual and emotional responses leading to rural work openness for such students.

Effects of Virtual Reality-Based Cognitive Training in the Elderly with and without Mild Cognitive Impairment.

ObjectiveThis study aimed to introduce a 4-week long fully immersive virtual reality-based cognitive training (VRCT) program that could be applied for both a cognitively normal elderly population and patients with mild cognitive impairment (MCI). In addition, we attempted to investigate the neuropsychological effects of the VRCT program in each group. MethodsA total of 56 participants, 31 in the MCI group and 25 in the cognitively normal elderly group, underwent eight sessions of VRCT for 4 weeks. In order to evaluate the effects of the VRCT, the Korean version of the Consortium to Establish a Registry for Alzheimer’s Disease Assessment Packet was administered before and after the program. The program’ s safety was assessed using a simulator sickness questionnaire (SSQ), and availability was assessed using the presence questionnaire. ResultsAfter the eighth session of the VRCT program, cognitive improvement was observed in the ability to learn new information, visuospatial constructional ability, and frontal lobe function in both groups. At the baseline evaluation, based on the SSQ, the MCI group complained of disorientation and nausea significantly more than the cognitively normal elderly group did. However, both groups showed a reduction in discomfort as the VRCT program progressed. ConclusionWe conclude that our VRCT program helps improve cognition in both the MCI group and cognitively normal elderly group. Therefore, the VRCT is expected to help improve cognitive function in elderly populations with and without MCI.

The Core Seminar Diaries: Wild Rides, Echoing Groups, and Explorations in Humanity

ABSTRACT The core seminar is the main site of supervision and reflective learning for candidates participating in the Community Psychoanalytic Track (CPT) of the Psychoanalytic Institute of Northern California (PINC). Using examples from the CPT’s collaborative projects in public agencies, the paper describes the functioning of the polyvocal supervision group that investigates roles and authority relationships through unconsciously-driven transference/countertransference dynamics between individuals and groups. Themes include: issues facing the agency’s client population; vicarious traumatization to agency staff; questions of framing and containment; application of community psychoanalytic theories; issues of privacy and discretion; termination challenges; and, the broader sociopolitical and cultural context. This immersive training experience helps integrate the community psychoanalytic paradigm into candidates’ worldview as future analysts.

Extended-Reality Technologies: An Overview of Emerging Applications in Medical Education and Clinical Care.

Extended-Reality Technologies: An Overview of Emerging Applications in Medical Education and Clinical Care.

Qualities of Effective Vital Anaesthesia Simulation Training Facilitators Delivering Simulation-Based Education in Resource-Limited Settings.

Lack of access to safe and affordable anesthesia and surgical care is a major contributor to avoidable death and disability across the globe. Effective education initiatives are a viable mechanism to address critical skill and process gaps in perioperative teams. Vital Anaesthesia Simulation Training (VAST) aims to overcome barriers limiting widespread application of simulation-based education (SBE) in resource-limited environments, providing immersive, low-cost, multidisciplinary SBE and simulation facilitator training. There is a dearth of knowledge regarding the factors supporting effective simulation facilitation in resource-limited environments. Frameworks evaluating simulation facilitation in high-income countries (HICs) are unlikely to fully assess the range of skills required by simulation facilitators working in resource-limited environments. This study explores the qualities of effective VAST facilitators; knowledge gained will inform the design of a framework for assessing simulation facilitators working in resource-limited contexts and promote more effective simulation faculty development. This qualitative study used in-depth interviews to explore VAST facilitators' perspectives on attributes and practices of effective simulation in resource-limited settings. Twenty VAST facilitators were purposively sampled and consented to be interviewed. They represented 6 low- and middle-income countries (LMICs) and 3 HICs. Interviews were conducted using a semistructured interview guide. Data analysis involved open coding to inductively identify themes using labels taken from the words of study participants and those from the relevant literature. Emergent themes centered on 4 categories: Persona, Principles, Performance and Progression. Effective VAST facilitators embody a set of traits, style, and personal attributes (Persona) and adhere to certain Principles to optimize the simulation environment, maximize learning, and enable effective VAST Course delivery. Performance describes specific practices that well-trained facilitators demonstrate while delivering VAST courses. Finally, to advance toward competency, facilitators must seek opportunities for skill Progression.Interwoven across categories was the finding that effective VAST facilitators must be cognizant of how context, culture, and language may impact delivery of SBE. The complexity of VAST Course delivery requires that facilitators have a sensitive approach and be flexible, adaptable, and open-minded. To progress toward competency, facilitators must be open to self-reflection, be mentored, and have opportunities for practice. The results from this study will help to develop a simulation facilitator evaluation tool that incorporates cultural sensitivity, flexibility, and a participant-focused educational model, with broad relevance across varied resource-limited environments.