Participant perceptions of virtual simulation to develop non-technical skills in health professionals

Abstract

Background

Research has identified that virtual simulations may be effective in developing non-technical skills including communication, teamwork and decision making. However, little is known about how participants perceive learning non-technical skills via engagement in virtual simulation.

Aims

The aim of this research was to investigate participant perceptions and the learning experiences when engaging in virtual simulations focused on developing non-technical skills.

Method

A descriptive exploratory approach was used. An online voluntary survey collected qualitative extended responses from participants after each virtual simulation. Ethics approval was obtained for the research and guidelines adhered to throughout the study.

Results

A total of 675 responses were obtained. Participants perceive that engaging with the virtual simulation made them aware of non-technical skills including communication, teamwork, decision making, critical thinking and problem solving, and, to a lesser extent, situational awareness. Additional categories of learning, clinical practice and limitations were identified.

Conclusions

Engaging in virtual simulation can develop awareness of non-technical skills, as well as confidence and vigilance in practice and mindfulness of a person-centred approach to healthcare. Engaging in virtual simulation may support change in the professional performance of the participants through role modelling and learning through error.

Keywords

acute care inter-professional learning inter-professional working patient safety qualitative virtual simulation

Introduction

Patient safety is at the forefront of healthcare and is an important construct in clinical practice for health professionals, managers, organisations, patients and families. A critical component of patient safety, considered important in error reduction, is non-technical skills. Non-technical skills are the cognitive, social and interpersonal skills required for safe and competent clinical performance (Flin et al., 2013). Non-technical skills include categories of communication, teamwork, decision making, situational awareness, leadership, coping with stress and managing fatigue. Failures in non-technical skills such as leadership, situation awareness, team working and decision making are linked to adverse events and medical error, resulting in unintentional, but at times serious harm to patients and contributing to patient death (Uramatsu et al., 2017).

Simulation is suggested to provide a robust and effective strategy to successfully develop non-technical skills (Unsworth et al., 2014). However, there are challenges in implementing simulations using traditional face-to-face approaches in clinical and educational settings. Simulation facilities and resources can be costly to build, maintain and run (Kelly et al., 2016). Face-to-face simulation is reported to be resource intensive regarding faculty, equipment and space (Bonnetain et al., 2010), with challenges described in scheduling activities (Andreatta et al., 2010). Additionally, there is limited opportunity for repetition of learning experiences across large numbers of learners (Liaw et al., 2016). Finally, although physiological responses in many human patient simulators can be repeated (Cumin et al., 2015), there are concerns over consistency of learning experiences and assessment of performance (Manz et al., 2013; Peterson et al., 2017), particularly when implementing multiple, simultaneous simulation experiences across large student cohorts.

Virtual simulation is suggested to provide a more sustainable approach that is flexible and reproducible and can be disseminated across large numbers of learners (Cant and Cooper, 2014). Virtual simulation provides a safe learning environment (Duff et al., 2016), permitting access to essential, but at times unavailable, clinical situations for practice and learning (Posel et al., 2009) and supports individual or team-based interactions (Cant and Cooper, 2014). In this paper, virtual simulation represents simulation activities with which learners engage via a computer screen, which involves videos of human actors as characters in real-world clinical encounters.

Traditionally, virtual simulation has been used to develop diagnostic and clinical reasoning in nursing students (Forsberg et al., 2016); however, advancements in technology, internet speed and educational methodologies (Cant and Cooper, 2014) have seen the development of virtual simulation to address more diverse areas of learning. Recent research has suggested that virtual patient simulations may be effective in developing non-technical skills, including communication, teamwork and decision making (Peddle et al., 2016). Some studies address elements of non-technical skills, such as teamwork training, communication and situation awareness; however no paper addresses the comprehensive suite of non-technical skill categories identified as critical components of safe and competent practice for health professionals. Additionally, the focus of the published research relates to the effectiveness of the resources in developing identified learning outcomes. No paper focuses on the learning experiences and perceptions of the participants engaging in virtual simulation to develop non-technical skills.

Research question

The aims of this research are to address the gap in the literature, explore participant learning experiences and investigate participants' perceptions of engaging in virtual simulation to develop non-technical skills. This research posed the following question: What are participant experiences and perceptions of engaging in virtual simulation activities to develop non-technical skills?

Virtual Simulated Patient Resource

The Virtual Simulated Patient Resource (VSPR, www.vspr.net.au) is web based and provides health professionals an opportunity to engage in virtual simulations to develop foundational knowledge, skill, attitudes and practice of non-technical skills. The VSPR enables participant-centred learning via constructivist approaches. Learning is an active process where the participant uses reflection and constructs knowledge based on past and current experiences (Rogers, 2011). Using a ‘choose your own adventure game’ approach, the virtual simulations present a patient narrative, portraying consequences of actions and decisions via a branching design (Bearman, 2003). Learners engage in the simulation as themselves. Based on cues presented in video vignettes of realistic clinical situations and characters, participants make decisions to advance the simulation. Feedback is inherent in the patient's clinical outcome, with debriefing concluding the simulation activity. The virtual simulations provided in VSPR, in the form of virtual patients, present a unique, holistic approach to the development of non-technical skills, as they aim to develop all categories of non-technical skills including teamwork, communication, leadership, situation awareness, decision making, coping with fatigue and managing stress. The VSPR site comprises seven virtual simulation scenarios. The virtual simulations have established learning outcomes (International Nursing Association for Clinical Simulation and Learning (INACSL) Standards Committee, 2016b) and enable facilitation to meet established best-practice criteria (INACSL Standards Committee, 2016a).

Method

Design

A qualitative descriptive exploratory approach was used to investigate participant experiences when engaging with the virtual simulations in the VSPR.

Data collection

An online, anonymous, voluntary survey collected extended qualitative responses from participants who engaged with the virtual simulation. The use of qualitative surveys with open-ended questions is deemed appropriate for investigation into new and emerging areas (Ahrweiler et al., 2014). Immediately after each simulation, participants were invited to take part in the research. In this study, the use of an open-ended survey immediately following the simulation aimed to capture the dominant reactive thinking of each participant to highlight their individual learning experience (Schiek and Ullrich, 2017). Participants were informed that their responses were anonymous, and responded to one open-ended question: What are your thoughts about the (scenario title) scenario? Data were automatically collated and stored on the server. Participants could respond to the survey multiple times after each simulation.

Research setting

The VSPR is a freely available web-based program accessed via registration on its website. Registration is open to all individuals with no limitation. During registration, participants used a tick-box approach to consent to be involved in research that uses anonymised data.

Population and sample

Recruitment to the study was not conducted. Participants who registered on the VSPR website between implementation in December 2013 and December 2017 and had consented to participate in the research comprised the study sample. During registration, participants recorded demographic details including level of education, specifying year if undergraduate, university or clinical venue and profession. Due to the anonymity of the data collected, it was not possible to identify the demographics of the participants in the sample relative to survey responses.

Data analysis

Data were analysed using inductive thematic analysis. Thematic analysis was selected to ensure participant voices were heard in this new area of research (Clarke and Braun, 2017). Data were downloaded from the website in CSV files and converted to Word documents for uploading into NVivo for analysis (QSR International, Version 11). Two research assistants independently undertook the inductive thematic data analysis. Data were read and re-read, with interesting factors identified as codes in NVivo. Final categories and subcategories were determined by review and discussion of the analyses with the author. To ensure they were grounded in the data, the author checked all final categories and sub-categories against coded passages.

Findings

Of the 9449 users who registered on the site between December 2013 and December 2017, 1892 consented to participate in research; of those registered, 376 accounts were inactive. A representation of current participants who registered and consented to take part in the research by profession is presented in Figure 1; level of education, including year if undergraduate student, is presented in Figure 2; and country of access is shown in Figure 3.

Figure 1.

Participants by profession.

Figure 2.

Participants by level of education.

Figure 3.

Country of origin.

A total of 675 responses were recorded in the online survey. The number of responses per scenario is identified in Table 1. Some of the responses comprised blank or indecipherable text and were excluded from analysis. The total sample included for analysis was n = 659. In total, 593 statements were coded, with four categories recognised in the data: non-technical skills, learning, clinical practice and limitations.

Table 1.

Number of responses per scenario.

Scenario	Number of responses	Number of responses discarded
Aggressive patient	71	3
Blood transfusion	108	2
Community feedback	65	0
Falls	325	10
Midwifery	11	0
Post-op	42	1
Team work	53	0
Total	675	16

Non-technical skills

Participants identified the virtual simulation that developed non-technical skills including communication, teamwork, decision making, situation awareness, and critical thinking and problem solving (Table 2).

Table 2.

Non-technical skills (n = 117, 20%).

Communication (n = 37, 6%)	‘The nurse used the blocking method to handle interruption. The doctor used a small debrief to pass on information to the nurse/team member.’ (Falls scenario)
Teamwork (n = 49, 8%)	‘I thought it was excellent example of multidisciplinary teamwork and thorough assessments that catch what is previously missed. it (sic) emphasises the importance of handovers/communication and thorough assessments and follow ups.’ (Warfarin in the community scenario)
Decision making (n=16, 3%)	‘I think its (sic) a fantastic scenario and has helped me in putting my thinking cap on and learning to make decisions from a health professional's point of view.’ (Ward round scenario)
Situation awareness (n = 4, 1%)	‘Very well done, scenario was good and allowed for critical thinking and analysing of the situation.’ (Blood transfusion scenario)
Critical thinking and problem solving (n = 11, 2%)	‘This scenario gave me an insight on problem-solving critical skills thinking and management of problem. Its (sic) a very good tool for students to learn and develop and idea of what to expect in a situation such as this.’ (Post-operative scenario)

Learning

Five sub-categories were identified in the learning category (Table 3). Overwhelmingly, participants indicated that the experience was positive, enriched via the interactive and engaging design of the activity, which required participant input to advance the simulation. The use of realistic clinical situations, portraying realistic professional performances and the opportunity to experience consequences of decisions, enabled participants to be immersed and present in the situation.

Table 3.

Learning (n = 256, 43%).

Positive experience (n = 151, 25%)	‘Fantastic scenario. Really enjoyed this.’ (Warfarin in the community scenario) ‘I thought the scenario was excellent.’ (Falls scenario) ‘I think it's a fantastic scenario.’ (Ward round scenario)
Interactive and engaging (n = 33, 6%)	‘I found it very helpful, makes it a lot clearer than just reading through requirements and notes. I think it will stick in my memory for longer as well.’ (Falls scenario) ‘I thought it was conducted in a clever way to keep viewers engaged. It was easy to retain information as you had a choice in the scenario not jus (sic) watching.’ (Falls scenario)
Realistic situations and characters (n = 40, 7%)	‘The Falls scenario was very helpful as it allowed us to think through the scenario and showed us some realistic distractions and errors that can occur in this type of situation.’ (Falls scenario) ‘It was very well acted and very well portrayed to being like a real-life scenario, thought provoking and engaging.’ (Aggressive patient scenario)
Consequences (n = 23, 4%)	‘The opportunity to make mistakes and the explanation as to why the other option would have been more beneficial really helped to me understand and clarify the situation. Also, because you are able to pause and rewind, it allowed you to research things to get a better understanding of the situation.’ (Ward round scenario) ‘I found it helpful to have different endings that were a result of which option we chose. It also helped me to understand how one little thing can change the outcome.’ (Falls scenario)
Presence (n = 9, 2%)	‘… The videos make it feel as thought (sic) it is real and helps to picture yourself in a similar situation.’ (Warfarin in the community scenario)

Clinical practice

Six subcategories were recognised in the clinical practice category (Table 4). The portrayal of ‘real’ clinical practice enabled clarification of the expectation of performance in practice and established the virtual simulations as relevant for practice. The provision of exemplars of good practice enabled role modelling. Additionally, the virtual simulations enabled participants to clarify and reinforce procedural skills, developing confidence in practice, and to appreciate the patient and family at the centre of the care interaction.

Table 4.

Clinical practice (n=139, 23%).

Real practice (n = 20, 3%)	‘I think that what you presented was a good interpretation of what often occurs in hospital due to staff shortage.’ (Blood transfusion scenario) ‘I thought it was quite realistic as there will be people running late to rounds or needing to leave early, therefore very important to explain the necessity of all healthcare workers involved being present and contributing.’ (Ward round scenario)
Person centred (n = 19, 3%)	‘Treating Michael as the patient needing care and not allowing his past history to be of more importance than the care he needs.’ (Aggressive patient scenario) ‘It is also important to involve the patient when making a care plan, and to give the patient feedback.’ (Ward round scenario) ‘An excellent scenario, which clearly revealed not only the physical impact on the patient but the emotional devastation on the relative.’ (Falls scenario)
Procedural skills (n = 33, 6%)	‘To check the patient's medical history to avoid blood transfusion errors. To check properly the name of the blood transfusion recipient. Check the name in the arm band.’ (Blood transfusion scenario) ‘It is informative in the sense that it allows the learner to remember the steps of safe blood transfusion.’ (Blood transfusion scenario) ‘Its (sic) a good scenario. Made me learn the intricacies involved in the management of patients post surgery who are on warfarin and how important it is to check their International Normalised Ratio (INR) levels once they recommence warfarin post surgery.’ (Post-operative scenario)
Relevance for practice (n=12, 2%)	‘Great learning tool that I'll be able to adapt into my practices.’ (Aggressive patient scenario) ‘I thought it was very realistic and made me genuinely think about what my actions would be if I was involved in this scenario.’ (Aggressive patient scenario) ‘I found this scenario to be very realistic, as in something I am likely to experience in the workplace.’ (Falls scenario)
Good exemplars (n = 25, 4%)	‘It was great seeing an example of great communication between the nurse and the doctor, and also seeing the nurse acting as the initiator and recommender in particular areas of the patient's care. The healthcare professionals vocalising every are (sic) they do and every thought they have relevant to the patient allows me to have a good understanding of the holistic picture of the patient's condition.’ (Post-operative scenario)
Confidence (n = 30, 5%)	‘…Allowed me to review correct procedures for administering blood products and gives me confidence in following the correct procedure in my clinical practice.’ (Blood transfusion scenario) ‘I found this scenario to be very realistic and feel comfortable with the decisions to make in this situation now.’ (Falls scenario)

Limitations were noted in the survey data, with five subcategories recognised (Table 5). Limitations to learning included lack of specific feedback, technical difficulties, unclear questions, limited options to progress the simulation and limited instructions.

Table 5.

Barriers to and limitations for learning (n = 81, 14%).

Lack of feedback (n = 14, 2%)	‘It didn't demonstrate questions clearly and feedback should be presented in detail too.’ (Aggressive patient scenario) ‘It would be handy if there was guidance on where I had gone wrong.’ (Warfarin in the community scenario) ‘It could be a little bit more interactive and show more theory as to why it would be better to do this, rather than that.’ (Falls scenario)
Technical difficulties (n = 10, 2%)	‘Great, but technically it is really slow in loading.’ (Aggressive patient scenario) ‘Option for lower-res video would be handy for those with low internet speed.’ (Falls scenario) ‘… I can't find the certificate of completion.’ (Falls scenario)
Unclear questions (n = 33, 6%)	‘The questions are a little confusing: can easily inadvertently (sic) make a mistake.’ (Post-operative scenario) ‘The apparent answers do not appear to be correct and hence, I feel that the wording of the questions asked may need to be made clearer?’ (Falls scenario) ‘A little confusing at first, the questions weren't very descriptive of the options selected.’ (Falls scenario)
Vague and limited options (n = 16, 3%)	‘The options are very broad and I was a bit confused with what they were asking.’ (Falls scenario) ‘Some of the answer options were too vague.’ (Aggressive patient scenario) ‘There were not the correct options offered to prevent her fall in this video, so the outcome would have always led to her falling. I have re-started the video a few times and it always leads to the same outcome.’ (Falls scenario)
Limited instructions (n = 8, 1%)	‘The instructions were not really that clear at the start of the assessment.’ (Blood transfusion scenario) ‘It's a bit confusing as to what it is you have to do.’ (Warfarin in the community)

Discussion

This study sought to investigate participant learning experiences and perceptions regarding the use and impact of virtual simulation, designed for health professionals learning non-technical skills. Participants detailed that learning via engagement with the virtual simulation developed awareness of non-technical skills including teamwork, communication, decision making, critical thinking and problem solving, with some reporting of situational awareness. A further three categories were recognised in the data: learning, clinical practice and limitations for learning.

Overwhelmingly, participants viewed the experience of engaging in the virtual simulation to develop non-technical skills as positive, with 25% of all statements coded to this sub-category. Participants stated they enjoyed the interactive experience of the ‘choose you own adventure game’, indicating the activity was interesting, enjoyable and creative. Many participants stated that the virtual simulation was ‘useful’ and ‘worthwhile’ for learning non-technical skills and was relevant to their practice. The learning experience when engaging with the virtual simulation was enjoyable and applicable and motivated learners to participate, which, in accordance with prior research, supports engagement in virtual environments and enhances learning (Alexander, 2018; Budhai, 2017).

Participant engagement in the virtual simulations was enhanced by active participation and experiential learning approaches (Budhai, 2017). Active participation involves placing participants in meaningful activities, requiring them to think about what they are seeing and hearing and the decisions they are making (Budhai, 2017). In the virtual simulation, participants are required to choose a course of action to advance the simulation, enabling active participation. Moreover, the use of realistic clinical situations, environments and characters supports experiential learning. The findings of this study suggest that the ability of the virtual simulation to enable learners ‘to go beyond the confines of the online classroom and connect their learning to the real world’ (Budhai, 2017: 2) may further promote learning related to non-technical skills.

The ability of participants to see consequences of decisions was emphasised as a positive element in learning non-technical skills via the virtual simulation. It is proposed that learning via error, partnered with feedback, results in more effective learning (Metcalfe, 2017). For learning by error to be effective, participants need to understand where the error was made, what the correct answer is and why (Metcalfe, 2017). Engaging in the virtual simulation enables participants to go back and repeat the activity and identify where the mistake happened, supporting clarification and understanding of the situation and correction of learning. Moreover, learning via errors can make participants more vigilant in practice, promoting transfer of learning to practice, supporting safe and competent patient care (Reime et al., 2016).

Responses to the virtual simulation ranged from participants finding the approach to be ‘a bit tricky’ and challenging to complete, to ‘Yeah it was good, fairly easy though…’. The variety of responses aligns with the range of participants registered on the site from novice undergraduate health professional students to experienced, expert practitioners (Benner, 1984). Novice learners tend to be rule bound, hence identifying cues and using discretionary judgement when situations deviate from the norm can be challenging (Benner, 1984). The lack of clinical experience may make it difficult for the novice learner to identify cues and use discretionary judgement as they are rule bound (Benner, 1984). Conversely, expert practitioners with vast clinical experience can easily and readily identify cues and acquire an intuitive grasp of the clinical situation as a whole (Benner, 1984). Accordingly, experts who have more flexibility in adapting skills to meet the needs of a clinical situation may find the learning activity ‘a bit easy’. Nevertheless, some participants who stated the simulation was ‘easy’ qualified that engaging in the virtual simulation remained a good learning experience. The findings of this study suggest that the virtual simulation may be useful across the learning continuum to clarify and reinforce knowledge, skills and attitudes related to non-technical skills. Further research is required to investigate the association between the level of learner and the perceived degree of complexity of the virtual simulation.

The findings of this research reinforce the importance of role modelling in health professional education, in developing a professional identity, professional behaviours, (Sternszus and Cruess, 2016) and confidence in clinical performance (Jack et al., 2017). Participants indicated that the portrayal of a ‘real’ clinical practice environment in the virtual simulation enabled them to understand the setting. The ability of the virtual simulation to depict the imperfect reality of practice, including exemplars of ‘good practice’, facilitated role modelling of expected behaviours in the clinical practice setting. Some participants clarified that this role modelling assisted them to translate the learning into practice. Additionally, participants suggested that engaging with the virtual simulations clarified practice related to procedural or technical skills. The ability of the virtual simulation to clarify technical skills and develop a clearer understanding of correct procedural steps and techniques may improve confidence and competence ‘with consequent, positive flow on effects on patient outcomes’ (Rivière et al., 2017: 1).

An interesting feature identified by some participants was the development of an awareness of the patient, family and significant others at the centre of care following engaging with the virtual simulation. The virtual simulation made participants aware of seeing the person and the significance of involving patients in all healthcare decisions. Person-centred care ‘places people as equal partners in addressing their individual healthcare needs’ (Hardy, 2015: 519). Being aware of the person at the centre of the care episode ensures that care is person centred, meeting the needs of the individual and enhancing positive and appropriate care outcomes (Hardy, 2015). Engaging with the virtual simulation should enhance participants’ awareness of the person at the centre of the care situation and promote more effective care interactions between the person in need of care and the health professional (Hardy, 2015). This finding reinforces previous research that identifies narrative approaches in virtual simulation, depicts the patient story and enables participants to experience the psychosocial aspects of a patient encounters (Bearman, 2003).

There were limitations identified by the participants that may have negatively affected learning. Some participants identified a lack of instruction and orientation to the activity, including how to engage with the simulation and what it was they, as participants, had to do. Participants identified that the options presented to advance the simulation were limited or not correct and the wording of some questions was confusing. The lack of orientation and the confusion during the learning activity may trigger learners to disengage and undermine learning (D’Mello et al., 2014). However, confusion is also suggested to be a positive emotion in learning when the participant is faced with a complex task (D’Mello et al., 2014). Due to the large numbers of novice learners (Figure 2), D’Mello et al. (2014) suggest that confusion would be the norm rather than an exception. One aspect that participants suggested would add to the learning experience was the provision of detailed feedback in the form of report or evaluation of performance at the end of the simulation. Although providing feedback is deemed important for learning as it provides a process during which learners obtain information about their performance, act on that information and generate improved work (Boud, 2015), participants in the present study reported learning from engaging in the virtual simulation without detailed feedback. However, the provision of a written summary may help participants understand ‘why they got it wrong’, which is important in learning by error (Metcalfe, 2017). The items identified above may warrant further consideration in order to mitigate interruptions in the learning process.

Strengths and limitations of the study

The broad open-ended survey question enables the dominant thinking of the participant to be captured immediately following the learning experience. Data were collected over a prolonged period and present continued observations. Independent data coding and use of discussion and consensus to identify categories strengthen findings and add credibility. Additionally, triangulation of data from multiple sources and a data audit, consisting of checking final categories against coded passages, adds credibility to the data analysis process. Participants have the option to consent to participate in studies with no impact of their access to the courses.

Although the results are drawn from a large population, the anonymous nature of the survey responses precludes generalisation of findings or further analysis. Additionally, the experience of the participants, including academic and clinical, has considerable variation and it is unknown whether participants completed the activity individually or in groups, which may impact participant perceptions. Participants may have responded to the survey more than once for each simulation activity, which may result in data arising from dominant participants and not being representative of the population. The use of a single question does not enable deeper exploration of interesting factors. Moreover, it is important to note that the author led the development, design and authorship of the virtual simulation project.

Recommendations

When implementing virtual simulations to develop non-technical skills, the findings of this study suggest virtual simulations require active participation and need to be underpinned by experiential learning. Virtual simulations should depict authenticity in the scenario, characters and setting and be appropriate to the learning needs of the participant audience. Participants should be able to experience consequences of decisions with feedback, to identify not only what the error was, but also why it occurred. Virtual simulation should provide exemplars and depict best practice for role modelling. Finally, virtual simulation needs to ensure clarity in instruction, wording of questions and suitable options to progress the simulation and limit confusion.

Conclusion

The findings of this study suggest that participating in the virtual simulation from VSPR is a positive and engaging learning experience, useful in developing awareness of non-technical skills including communication, teamwork, decision making, situational awareness, critical thinking and problem solving. Findings also suggest that engaging in virtual simulation may support development of clinical performance and confidence of participants through role modelling and learning through error. An unexpected finding of the study is the development of awareness of a person-centredness in participants, which may support the inclusion of the patient as a member of the healthcare team. Finally, addressing some identified limitations may further improve the learning experiences of participants when engaging with virtual simulations in VSPR.

Further research is required to explore the learning experiences of expert practitioners and the application of the virtual simulation in continuing professional development settings. Additionally, the ability of participants to transfer learning developed from engaging with the virtual simulation to practice in the clinical setting in patient care interactions requires deeper exploration.

Key points for policy, practice and/or research

Virtual simulation supports development of awareness of non-technical skills including communication, teamwork, decision making, critical thinking and problem solving and situational awareness.

Learning in the virtual simulation is supported by interactive, engaging activities that portray realistic situations and characters that are relevant for practice, enabling participants to feel present in the situation and experience consequences of actions and visualisation of situations.

Engaging in virtual simulation enables participants to develop confidence in their own practice by providing an insight into real clinical practice, exemplars of good practice and clarification of procedural and technical information, while emphasising the patient at the centre of care.

Limitations for learning include lack of clear feedback and orientation, unclear and confusing questions, and limited options and instructions.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethical permission

Ethics approval was obtained for the research and guidelines adhered to throughout the study (ethics approval ID number: CF12/3958 – 2012001891). The facility for ethics approval was Monash University.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Monica Peddle is the Undergraduate Nursing Course Coordinator for the School of Nursing and Midwifery at La Trobe University, Melbourne, Australia. Monica has extensive clinical experience and widespread academic experience as a lecturer in nursing extending to senior research fellow. She has established expertise in teaching and learning in undergraduate and postgraduate health professional programmes with a particular focus on virtual learning and simulation. Monica is a PhD candidate, with her thesis focusing on exploring the experience of undergraduate health professionals in interactions with virtual patients to develop non-technical skills.

References

Ahrweiler

Neumann

Goldblatt

et al. (2014) Determinants of physician empathy during medical education: Hypothetical conclusions from an exploratory qualitative survey of practicing physicians. BMC Medical Education 14: 122.

Alexander

(2018) The relevance of relevance for learning and performance. The Journal of Experimental Education 86: 124–135.

Andreatta

Maslowski

Petty

et al. (2010) Virtual reality triage training provides a viable solution for disaster-preparedness. Academic Emergency Medicine 17: 870–876.

Bearman

(2003) Is virtual the same as real? Medical students' experiences of a virtual patient. Academic Medicine 78: 538–545.

Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, Calif: Addison-Wesley Pub., Nursing Division.

Bonnetain

Boucheix

J-M

Hamet

et al. (2010) Benefits of computer screen-based simulation in learning cardiac arrest procedures. Medical Education 44: 716–722.

Boud

(2015) Feedback: Ensuring that it leads to enhanced learning. The Clinical Teacher 12: 3–7.

Budhai S and Skipwith, Ke'Anna Brown. (2017). Best practices in engaging online learners through active and experiential learning strategies (Best practices in online teaching and learning series). New York; London, Routledge.

Cant

Cooper

(2014) Simulation in the Internet age: The place of web-based simulation in nursing education. An integrative review. Nurse Education Today 34: 1435–1442.

10.

Clarke

Braun

(2017) Thematic analysis. The Journal of Positive Psychology 12: 297–298.

11.

Cumin

Chen

Merry

(2015) Measuring the repeatability of simulated physiology in simulators. Simulation in Healthcare 10: 336–344.

12.

D'Mello

Lehman

Pekrun

et al. (2014) Confusion can be beneficial for learning. Learning and Instruction 29: 153–170.

13.

Duff

Miller

Bruce

(2016) Online virtual simulation and diagnostic reasoning: A scoping review. Clinical Simulation in Nursing 12: 377–384.

14.

Flin

O'Connor

Crichton

(2013) Safety at the Sharp End: A Guide to Non-technical Skills, Farnham: Ashgate Publishing, Ltd.

15.

Forsberg

Ziegert

Hult

et al. (2016) Assessing progression of clinical reasoning through virtual patients: An exploratory study. Nurse Education in Practice 16: 97–103.

16.

Hardy

(2015) Perspectives: Is health and social care person centred? Hello, my name is not enough. Journal of Research in Nursing 20: 517–522.

17.

International Nursing Association for Clinical Simulation and Learning (INACSL) Standards Committee (2016a) INACSL Standards of Best Practice: Simulation^SM Facilitation. Clinical Simulation in Nursing 12: S16–S20.

18.

International Nursing Association for Clinical Simulation and Learning (INACSL) Standards Committee (2016b) INACSL Standards of Best Practice: Simulation^SM Outcomes and Objectives. Clinical Simulation in Nursing 12: S13–S15.

19.

Jack

Hamshire

Chambers

(2017) The influence of role models in undergraduate nurse education. Journal of Clinical Nursing 26: 4707–4715.

20.

Kelly

Hopwood

Rooney

et al. (2016) Enhancing students' learning through simulation: Dealing with diverse, large cohorts. Clinical Simulation in Nursing 12: 171–176.

21.

Liaw

Wong

Lim

EYP

et al. (2016) Effectiveness of a web-based simulation in improving nurses' workplace practice with deteriorating ward patients: A pre-and postintervention study. Journal of Medical Internet Research 18.

22.

Manz

Hercinger

Todd

et al. (2013) Improving consistency of assessment of student performance during simulated experiences. Clinical Simulation in Nursing 9: e229–e233.

23.

Metcalfe

(2017) Learning from errors. Annual Review of Psychology 68: 465–489.

24.

Peddle

Bearman

Nestel

(2016) Virtual patients and nontechnical skills in undergraduate health professional education: An integrative review. Clinical Simulation in Nursing 12: 400–410.

25.

Peterson

Watts

Epps

et al. (2017) Simulation faculty development: A tiered approach. Simulation in Healthcare 12: 254–259.

26.

Posel

Fleiszer

Shore

(2009) 12 Tips: Guidelines for authoring virtual patient cases. Medical Teacher 31: 701–708.

27.

Reime

Johnsgaard

Kvam

et al. (2016) Simulated settings; powerful arenas for learning patient safety practices and facilitating transference to clinical practice: A mixed method study. Nurse Education in Practice 21: 75–82.

28.

Riviére E, Saucier D, Lafleur A, Lacasse M and Chiniara G (2018). Twelve tips for efficient procedural simulation. edical teacher 40(7): 743–751.

29.

Rogers

(2011) Developing simulations in multi-user virtual environments to enhance healthcare education. British Journal of Educational Technology 42: 608–615.

30.

Schiek

Ullrich

(2017) Using asynchronous written online communications for qualitative inquiries: A research note. Qualitative Research 17: 589–597.

31.

Sternszus

Cruess

(2016) Learning from role modelling: Making the implicit explicit. The Lancet 387: 1257–1258.

32.

Unsworth

Melling

Allan

et al. (2014) Assessing human factors during simulation: The development and preliminary validation of the rescue assessment tool. Journal of Nursing Education and Practice 4: 52.

33.

Uramatsu

Fujisawa

Mizuno

et al. (2017) Do failures in non-technical skills contribute to fatal medical accidents in Japan? A review of the 2010–2013 national accident reports. BMJ Open 7: e013678.