Measuring participants' immersion in healthcare simulation: the development of an instrument

Towards reconciling usability and usefulness of policy explanations for sequential decision-making systems

Safefy-critical domains often employ autonomous agents which follow a sequential decision-making setup, whereby the agent follows a policy to dictate the appropriate action at each step. AI-practitioners often employ reinforcement learning algorithms to allow an agent to find the best policy. However, sequential systems often lack clear and immediate signs of wrong actions, with consequences visible only in hindsight, making it difficult to humans to understand system failure. In reinforcement learning, this is referred to as the credit assignment problem. To effectively collaborate with an autonomous system, particularly in a safety-critical setting, explanations should enable a user to better understand the policy of the agent and predict system behavior so that users are cognizant of potential failures and these failures can be diagnosed and mitigated. However, humans are diverse and have innate biases or preferences which may enhance or impair the utility of a policy explanation of a sequential agent. Therefore, in this paper, we designed and conducted human-subjects experiment to identify the factors which influence the perceived usability with the objective usefulness of policy explanations for reinforcement learning agents in a sequential setting. Our study had two factors: the modality of policy explanation shown to the user (Tree, Text, Modified Text, and Programs) and the "first impression" of the agent, i.e., whether the user saw the agent succeed or fail in the introductory calibration video. Our findings characterize a preference-performance tradeoff wherein participants perceived language-based policy explanations to be significantly more useable; however, participants were better able to objectively predict the agent's behavior when provided an explanation in the form of a decision tree. Our results demonstrate that user-specific factors, such as computer science experience (p < 0.05), and situational factors, such as watching agent crash (p < 0.05), can significantly impact the perception and usefulness of the explanation. This research provides key insights to alleviate prevalent issues regarding innapropriate compliance and reliance, which are exponentially more detrimental in safety-critical settings, providing a path forward for XAI developers for future work on policy-explanations.

Impact of pre-registration extended immersive ward-based simulation on student learning in preparation for clinical placement

BACKGROUND

Graduate nurses commonly experience significant challenges in transitioning to professional practice. The practice readiness of graduate nurses continues to be a concern for nurse educators and industry partners. Introduction of pre-registration extended immersive ward-based simulation can provide opportunities for students to practice the role of registered nurse before graduation. It is not clear if participation in simulation-based learning transfers to increased preparedness for dealing with real-life situations following entry into the workforce.

OBJECTIVE

To report on student views on how ward-based immersive simulation assisted in preparing for clinical placement and graduate practice.

DESIGN

A qualitative, descriptive design was used to conduct a series of face-to-face focus groups.

SETTING

School of Nursing and Midwifery metropolitan Western Australian university.

PARTICIPANTS

Final year baccalaureate nursing students who had participated in six four-hour simulation workshops between February and April 2021 were selected through purposive sampling.

METHODS

Focus group and interview data was transcribed from audio recordings. A six-phase approach was used to analyse data into themes and sub-themes. The study adhered to the consolidated criteria for reporting of qualitative research.

RESULTS

Three focus groups and one interview were conducted. Eight themes emerged. Student learning was identified as occurring in a variety of ways, such as how to work as a team and was influenced by a number of factors, such as the capacity for students to self-reflect.

CONCLUSIONS

Learning opportunities for students to practice how to think and work independently as a registered nurse is something that can be supported by pre-registration extended immersive ward-based simulation. Understanding of what will be expected of them once qualified can make students more prepared for professional practice enabling them to apply knowledge gained from simulated experiences to a similar situation as a graduate nurse.

Perception of Realism and Acquisition of Clinical Skills in Simulated Pediatric Dentistry Scenarios

Simulation, depending on the modality and fidelity of the scenarios, is an important resource for clinical teaching and achievement of learning outcomes in dentistry. The objectives of this study were to compare the degree of realism perceived by students and teachers in a simulated scenario, and to assess the level of competence acquired by the students.

METHOD

In the Pediatric Dentistry course, eight clinical scenarios were carried out, each one using a modified Erler Zimmer child simulator (handmade), a professional actress and two students (dentist and assistant) on the same pediatric dentistry case consisting of a pulp abscess in tooth 8.5. A total of 114 students in the 4th year of dentistry studies participated in the pediatric dentistry course. Questionnaires with Likert-type answers were elaborated to evaluate the educational intervention, applying them before and after the simulation.

RESULTS

The realism best valued by the students was that of the simulated participant and the worst that of the manikin, the latter being strongly related to the realism of the office. It was observed that students' perception of clinical competence increased as the overall realism of the scenario increased (p-value = 0.00576).

CONCLUSION

This research suggests that the creation of scenarios using handmade mannequins and simulated participants achieves a high level of realism, increasing the level of clinical competence perceived by dental students.

Development and psychometric testing of learning immersion scale in clinical simulation: A methodological study

BACKGROUND

Immersion during clinical simulation has been suggested to be important for learning effects. However, no valid and reliable instruments have been available for measuring the learner's immersion during simulation experience.

OBJECTIVES

To develop a Learning Immersion Scale in Simulation (LISS) and evaluate its psychometric properties.

DESIGN

A methodological study design was employed to develop and validate the instrument.

SETTINGS

Two universities in South Korea.

PARTICIPANTS

A convenience sample of 204 nursing students.

METHODS

A literature review and a focus group interview were conducted to determine the properties of learning immersion during simulation experience. Content validity was assessed by a panel of 10 experts. Nursing students who participated in high-fidelity patient simulation (n = 204) were asked to complete the preliminary LISS, after which Students Satisfaction and Self-Confidence in Learning Scale and Learning Flow Scale for Adults were administered for assessing the convergent and criterion validity. Data were analyzed using exploratory factor analyses, Pearson's correlation, and Cronbach's alpha.

RESULTS

Exploratory factor analyses extracted a four-factor solution, explaining 65.2% of the total variance. The convergent and criterion validity and internal consistency and half reliability were satisfied.

CONCLUSIONS

The LISS is a short multi-dimensional instrument with good psychometric validity and reliability that has potential utility for clinical simulation education and research.

Influence of presence in an inter-professional simulation training of the emergency caesarean section: a cross-sectional questionnaire study

Purpose

Emergency training using simulation is a method to increase patient safety in the delivery room. The effect of individual training concepts is critically discussed and requires evaluation. A possible influence factor of success can be the perceived reality of the participants. The objective of this study was to investigate whether the presence in a simulated emergency caesarean section improves subjective effect of the training and evaluation.

Methods

In this observation study, professionals took part in simulated emergency caesarean sections to improve workflow and non-technical skills. Presence was measured by means of a validated questionnaire, effects and evaluation by means of a newly created questionnaire directly after the training. Primary outcome was a correlation between presence and assumed effect of training and evaluation.

Results

106 participants (70% of course participants) answered the questionnaires. Reliability of the presence scale was good (Cronbach’s alpha 0.72). The presence correlated significantly with all evaluated items of non-technical skills and evaluation of the course. The factor “mutual support” showed a high effect size (0.639), the overall evaluation of the course (0.395) and the willingness to participate again (0.350) a medium effect. There were no differences between the professional groups.

Conclusion

The presence correlates with the assumed training objectives and evaluation of the course. If training is not successful, it is one factor that needs to be improved.

Teaching the management of trauma patients through virtual reality

INTRODUCTION

Virtual reality (VR) fully immersive interactive video teaching (VR FIIT) allows learners to develop through observing and interacting with complex realistic environments, developing technical and nontechnical skills. One such complex clinical environment is managing a trauma patient. Despite the significant developments in managing these patients, foundation doctors are frequently highly anxious due to their limited knowledge and experience. The aim of this project was twofold; to improve foundation doctor performance of managing trauma patients and to reduce their associated anxiety, through the use of VR teaching.

METHODS

A total of 14 foundation doctors were divided into two groups. One group underwent departmental teaching. The second group underwent departmental teaching and VR FIIT. We assessed the doctors via two methods. First, time taken to complete tasks correctly in trauma simulations was compared. Second, the doctors completed a self-reported level-based assessment questionnaire regarding anxiety and stress around trauma calls.

RESULTS

The VR FIIT intervention group were able to complete each task on average 118s faster than the standard group. The standard group missed essential tasks such as C-spine immobilisation. The VR FIIT group self-reported significantly lower levels of anxiety related to trauma calls.

CONCLUSION

VR teaching improves foundation doctor performance at managing simulated major trauma patients and decreases foundation doctor anxiety towards management and exposure of these clinical situations.

Change of collective orientation through an interprofessional training with medical students and student nurses depending on presence and professional group

BACKGROUND

Teamwork is an important success factors for patient treatment. The willingness of a healthcare provider to work in a team can be descripted with the construct of "Collective Orientation" (CO). The level of CO can be trained and is related to team performance. In this study, we investigated the effect of a simulator-based interprofessional training on the subject of patient fall in a hospital setting upon participations CO. To evaluate whether the course could be integrated into a longitudinal education concept, the participants were medical students and student nurses. Since effects of simulations can be influenced by the perceived reality, the results were measured as a function of Presence.

METHOD

In this observation study, 62 medical students and student nurses took part in six one-day interprofessional simulation trainings with the topic patient fall. The primary outcome was the mean difference between the CO measured immediately before (T1) and after the training (T2). The Presence of the participants was measured by questionnaire immediately after the course (T2).

RESULTS

Cronbach´s alpha for all scales and measurement points was higher than 0.69. CO increases over all professional groups from M = 3.42 (SD = 0.39) to M = 3.68 (SD = 0.54) significantly (p < .00; r = .5). Only the subscale "Dominance" in the professional group of the student nurses did not increase significantly. There was no correlation between Presence and the change in CO.

CONCLUSION

The questionnaires of CO and Presence can be applied to medical students and student nurses. The simulation course with the topic patient fall influences the CO and can be integrated in a longitudinal curriculum of teamwork training. The subscale "Dominance" of student nurses did not change. Preparatory learning units may increase the effects. The perceived reality of the scenario is not a main success factor.

Development, production and evaluation of 2-dimensional transfer tattoos to simulate skin conditions in health professions education

BACKGROUND

Moulages can greatly extend the possibilities of simulation in teaching and assessment. Since moulages that fit an educator's exact needs are often unavailable commercially, this paper explains how 2-dimensional transfer tattoos can be independently developed, produced, and evaluated.

METHODS

From representative photographs of the specific skin condition an analogue copy of the pathological finding is drawn. Once validated by the medical expert, it can be digitized by scanning and processed using graphics software. The final digital image file is printed onto transfer paper. Once applied and fixed onto the intended wearer, usually a simulated patient, its authenticity can be confirmed, and further transfer tattoos can be produced.

RESULTS

Using this moulage technique we produced 10 different 2-dimensional transfer tattoos to date, including hematoma, Janeway lesions and splinter nails. These moulages are used in clinical skills training, formative and high-stakes summative assessment in undergraduate medical and nursing programs.

CONCLUSIONS

By sharing our development process for 2-dimensional transfer tattoos, health profession educators can produce their own that best fit their local educational needs. Due to their high authenticity and standardization, 2-dimensional transfer tattoos are ideal for use in high-stakes assessment.

Simulation as a Training Method for Electricity Workers' Safety

Background: Simulation is a useful method to improve learning and increase the safety of work operations, both for technical and non-technical skills. However, the observation, assessment, and feedback about these skills is particularly complex, because the process needs expert observers, and the feedback could be judgmental and ineffective. Therefore, a structured process to develop effective simulation scenarios and tools for the observation and feedback about performance is crucial. To this aim, in the present research, we developed a training model for electricity distribution workers, based on high fidelity simulation. Methods: We designed simulation scenarios based on real cases, developed, and tested a set of observation and rating forms for the non-technical skills behavioral markers, and we tracked behaviors based on non-verbal cues (physiological and head orientation parameters). Results: The training methodology proved to be highly appreciated by the participants and effective in fostering reflexivity. An in-depth analysis of physiological indexes and behaviors compliant to safety procedures revealed that breath rate and heart rate patterns commonly related with mindful and relaxed states were correlated with compliant behaviors, and patterns typical of stress and anxiety were correlated with non-compliant behaviors. Conclusions: a new training method based on high fidelity simulation, addressing both technical and non-technical skills is now available for fostering self-reflection and safety for electricity distribution workers. Future research should assess the long-term effectiveness of high-fidelity simulation for electricity workers, and should investigate non-invasive and real-time methods for tracking physiological parameters.

Effects of surgical flow disruptions on surgeons' resources: a pilot study

BACKGROUND

Minimally invasive surgery requires surgeons to allocate more attention and efforts than open surgery. A surgeon's pool of resource is affected by the multiple occurrences of interruptions and distractions in the operating room. Surgical flow disruption has been addressed from a quantitative perspective. However, little is known on its impact on the surgeons' physiological resources.

METHODS

Three physiological markers, heat flux (HF), energy expenditure in metabolic equivalent of tasks and galvanic skin response were recorded using body sensor monitoring during the 21 surgical operations. The three markers, respectively, represent: stress, energy mobilization and task engagement. A total of 8 surgeons with different levels of expertise (expert vs. novice) were observed performing 21 surgical procedures categorized as short versus long. Factors of distractions were time-stamped, and triangulated with physiological markers. Two cases illustrate the impact of surgical flow disruptions on the surgeons.

RESULTS

The results indicate that expert surgeons' mental schemata are better organized than novices. Additionally, the physiological markers indicate that novice surgeons display a higher HF at the start (tendency p = .059) and at the end of procedures (p = .001) when compared to experts. However, during longer procedures, expert surgeons have higher HF at the start (p = .041) and at the end (p = .026), than at the start and end of a short procedure.

CONCLUSION

Data collected during this pilot study showed that interruptions and disruptions affect novice and expert surgeons differently. Surgical flow disruption appears to be taxing on the surgeons' mental, emotional and physiological resources; as a function of the length and nature of the disruptions. Several training curricula have incorporated the use of virtual reality programs to train surgeons to cope with the new technology and equipment. We recommend integrating interruptions and distractions in virtual reality training programs as these impact the surgeons' pool of resources.

Simulating a self-inflicted facial gunshot wound with moulage to improve perceived realism, immersion, and learning in simulation-based airway management training

Moulage is used to create mock wounds and injuries for clinical education and training. We developed a moulage technique to simulate a facial gunshot wound for use in simulation-based training. We removed sections of a manikin’s face and used moulage materials to mock various aspects of the wound. The manikin was used in a simulated scenario that teaches clinicians how to manage a complicated airway. The moulage was evaluated with a self-report questionnaire that assessed participants’ perceptions of the realism of the wound, the degree to which the wound contributed to their scenario immersion, and the degree to which the wound enhanced their learning experience on a 5-point Likert scale ranging from ‘strongly disagree’ to ‘strongly agree’. Participants’ average response to each item was significantly higher than the neutral midpoint, and the median response was ‘strongly agree’. Our work suggests that the simulated facial gunshot wound contributed to perceived scenario immersion and enhancement of the learning experience, supporting existing literature that suggests moulage is a valuable tool in healthcare simulation. Future work could investigate the effect of moulage using objective measures and explore the potential to use extended reality technology in conjunction with moulage to improve immersion even further.

How does moulage contribute to medical students' perceived engagement in simulation? A mixed-methods pilot study

Introduction

Moulage is used frequently in simulation, with emerging evidence for its use in fields such as paramedicine, radiography and dermatology. It is argued that moulage adds to realism in simulation, although recent work highlighted the ambiguity of moulage practice in simulation. In the absence of knowledge, this study sought to explore the impact of highly authentic moulage on engagement in simulation.

Methods

We conducted a randomised mixed-methods study exploring undergraduate medical students' perception of engagement in relation to the authenticity moulage. Participants were randomised to one of three groups: control (no moulage, narrative only), low authenticity (LowAuth) or high authenticity (HighAuth). Measures included self-report of engagement, the Immersion Scale Reporting Instrument (ISRI), omission of treatment actions, time-to-treat and self-report of authenticity. In combination with these objective measures, we utilised the Stimulated Recall (SR) technique to conduct interviews immediately following the simulation.

Results

A total of 33 medical students participated in the study. There was no statistically significant difference between groups on the overall ISRI score. There were statistically significant results between groups on the self-reported engagement measure, and on the treatment actions, time-to-treat measures and the rating of authenticity. Four primary themes ((1) the rules of simulation, (2) believability, (3) consistency of presentation, (4) personal knowledge ) were extracted from the interview analysis, with a further 9 subthemes identified ((1) awareness of simulating, (2) making sense of the context (3) hidden agendas, (4) between two places, (5) dismissing, (6) person centredness, (7) missing information (8) level of training (9) previous experiences).

Conclusions

Students rate moulage authenticity highly in simulations. The use of high-authenticity moulage impacts on their prioritisation and task completion. Although the slower performance in the HighAuth group did not have impact on simulated treatment outcomes, highly authentic moulage may be a stronger predictor of performance. Highly authentic moulage is preferable on the basis of optimising learning conditions.

The Effects of Integrated IT Support on the Prehospital Stroke Process: Results from a Realistic Experiment

Stroke is a serious condition and the stroke chain of care is a complex. The present study aims to explore the impact of a computerised decision support system (CDSS) for the prehospital stroke process, with focus on work processes and performance. The study used an exploratory approach with a randomised controlled crossover design in a realistic contextualised simulation experiment. The study compared clinical performance among 11 emergency medical services (EMS) teams of 22 EMS clinicians using (1) a computerised decision support system (CDSS) and (2) their usual paper-based process support. Data collection consisted of video recordings, postquestionnaires and post-interviews, and data were analysed using a combination of qualitative and quantitative approaches. In this experiment, using a CDSS improved patient assessment, decision making and compliance to process recommendations. Minimal impact of the CDSS was found on EMS clinicians' self-efficacy, suggesting that even though the system was found to be cumbersome to use it did not have any negative effects on self-efficacy. Negative effects of the CDSS include increased on-scene time and a cognitive burden of using the system, affecting patient interaction and collaboration with team members. The CDSS's overall process advantage to the prehospital stroke process is assumed to lead to a prehospital care that is both safer and of higher quality. The key to user acceptance of a system such as this CDSS is the relative advantages of improved documentation process and the resulting patient journal. This could improve the overall prehospital stroke process.

Starting to Think Like an Expert: An Analysis of Resident Cognitive Processes During Simulation-Based Resuscitation Examinations

STUDY OBJECTIVE

Simulation is commonly used to teach crisis resource management skills and assess them in emergency medicine residents. However, our understanding of the cognitive processes underlying crisis resource management skills is limited because these processes are difficult to assess and describe. The objective of this study is to uncover and characterize the cognitive processes underlying crisis resource management skills and to describe how these processes vary between residents according to performance in a simulation-based examination.

METHODS

Twenty-two of 24 eligible emergency medicine trainees from 1 tertiary academic center completed 1 or 2 resuscitation-based examinations in the simulation laboratory. Resident performance was assessed by a blinded expert using an entrustment-based scoring tool. Participants wore eye-tracking glasses that generated first-person video that was used to augment subsequent interviews led by an emergency medicine faculty member. Interviews were audio recorded and then transcribed. An emergent thematic analysis was completed with a codebook that was developed by 4 research assistants, with subsequent analyses conducted by the lead research assistant with input from emergency medicine faculty. Themes from high- and low-performing residents were subsequently qualitatively compared.

RESULTS

Higher-performing residents were better able to anticipate, selectively attend to relevant information, and manage cognitive demands, and took a concurrent (as opposed to linear) approach to managing the simulated patient.

CONCLUSION

The results provide new insights into residents' cognitive processes while managing simulated patients in an examination environment and how these processes vary with performance. More work is needed to determine how best to apply these findings to improve crisis resource management education.

Research challenges in prehospital care: the need for a simulation-based prehospital research laboratory

There is a need for improved research in the field of prehospital care. At the same time, there are many barriers in prehospital research due to the complex context, posing unique challenges for research, development, and evaluation. The present paper argues for the potential of simulation for prehospital research, e.g., through the development of an advanced simulation-based prehospital research laboratory. However, the prehospital context is different from other healthcare areas, which implies special requirements for the design of this type of laboratory, in terms of simulation width (including the entire prehospital work process) and depth (level of scenario detail). A set of features pertaining to simulation width, scenario depth, equipment, and personnel and competence are proposed. Close tailoring between these features and the prehospital research problems and context presents great potential to improve and further prehospital research.

The use of simulation and moulage in undergraduate diagnostic radiography education: A burns scenario

INTRODUCTION

There is a national drive to increase allied health professions simulation training. However, there is a paucity of literature within diagnostic radiography in relation to clinical simulation. No research could be found regarding the impact of simulation in radiography with complex clinical burns scenarios. This research aims to explore the perceptions of radiography undergraduate students regarding their preparedness for the complex care requirements in imaging examinations of clinical burns cases using a mixed methods approach.

METHOD

A small-scale simulation-based teaching session was developed in a Scottish HEI, using role play and moulage to create realism. Twenty-eight undergraduate student radiographers participated in the scenario. Students completed pre and post-scenario questionnaires using Likert scale and free response data. Focus groups were undertaken three months after the simulation to obtain rich qualitative data. Common themes were identified via a process of initial coding and a 6-phase thematic analysis.

RESULTS

Thematic analysis demonstrated a marked increased perception of preparedness post-scenario; students felt more prepared to undertake their role in the imaging of complex care patients (Likert scoring increased with both mode and median post-scenario). Common themes that were identified were patient centeredness, realism and learning.

CONCLUSION

Within this limited pilot project, the use of simulation was an effective means of preparing students to understand their role within the complex care setting (with respect to the traumatic realism of burns) in preparedness for professional practice. Additionally, students related to the practical understanding of the complexity of human factors that exist within clinical practice.

Simulation as a means to develop firefighters as emergency care professionals

Objective. The aim of this study was to evaluate the simulated emergency care performed by firefighters and their perception of simulation as an educational method. Methods. This study had a mixed method with both a quantitative and a qualitative approach. Data were collected by simulation assessment, a questionnaire and written comments. Descriptive analysis was conducted on the quantitative data whereas a qualitative content analysis was conducted on the qualitative data. Finally, a contingent analysis was used where a synthesis configured both the quantitative and the qualitative results into a narrative result. Results. The cognitive workload that firefighters face during simulated emergency care is crucial for learning. In this study, the severity and complexity of the scenarios provided were higher than expected by the firefighters. Clearly stated conditions for the simulation and constructive feedback were considered positive for learning. Patient actors induced realism in the scenario, increasing the experience of stress, in comparison to a manikin. Conclusion. Simulation in a realistic on-scene environment increases firefighters' cognitive ability to critically analyze problems and manage emergency care. Simulation of emergency care developed the firefighters as professionals.

Is there a role for simulation based education within conventional diagnostic radiography? A literature review

INTRODUCTION

Simulation based education is advancing, but is there a role for it in Diagnostic Radiography? The aim of this literature review was to understand the use of simulation within conventional diagnostic radiography education to raise awareness of this pedagogical approach. Objectives were to identify the prevalence and stage of delivery in education; understand the variation of simulation and learning objectives informing its use; and review the perceptions of those using simulation in education and practice.

METHODS

The literature review used a systematic search strategy. Library Plus, CINAHL, ScienceDirect, Medline and Google Scholar were reviewed resulting in 703 articles. Inclusion and exclusion criteria were applied with initial review of title and abstract resulting in 22 articles. Fifteen articles were selected following full text review.

RESULTS

Simulation was used for both pre-and post-registration education. Themes included inter-professional education, use of computer software and improving patient/practitioner interactions. Increased confidence and understanding of professional roles were common outcomes.

CONCLUSION

Simulation is a valuable pedagogical approach for diagnostic radiography education. Staff training and careful implementation of each stage is required to achieve desired learning outcomes.

Acute stress in residents playing different roles during emergency simulations: a preliminary study

OBJECTIVES

To investigate acute stress response in residents playing nurse and physician roles during emergency simulations.

METHODS

Sixteen second-year internal medicine residents participated in teams of four (two playing physician roles and two playing nurse roles). Stress markers were assessed in 24 simulations at baseline (T1) and immediately after the scenario (T2), using heart rate, systolic and diastolic blood pressure, salivary α-amylase, salivary cortisol and salivary interleukin-1β. The State-Trait Anxiety Inventory was applied at T2. Continuous data were summarized for the median (1st-3rd interquartile ranges), and the Mann-Whitney U Test was used to compare the groups.

RESULTS

The percent variations of the stress markers in the physician and nurse roles, respectively, were the following: heart rate: 70.5% (46.0-136.5) versus 53.0% (29.5-117.0), U=89.00, p=0.35; systolic blood pressure: 3.0% (0.0-10.0) versus 2.0% (-2.0-9.0), U=59.50, p=0.46; diastolic blood pressure: 5.5% (0.0-13.5) versus 0.0% (0.0-11.5), U=91.50, p=0.27; α-amylase: -5.35% (-62.70-73.90) versus 42.3% (12.4-133.8), U=23.00, p=0.08; cortisol: 35.3% (22.2-83.5) versus 42.3% (12.4-133.8), U=64.00, p=0.08); and interleukin-1β: 54.4% (21.9-109.3) versus 112.55% (29.7-263.3), U= 24.00, p=0.277. For the physician and nurse roles, respectively, the average heart rate was 101.5 (92.0-104.0) versus 91.0 (83.0-99.5) beats per minute, U=96.50, p=0.160; and the state anxiety inventory score was 44.0 (40.0-50.0) versus 42.0 (37.50-48.0) points, U= 89.50, p=0.319.

CONCLUSIONS

Different roles during emergency simulations evoked similar participants' engagement, as indicated by acute stress levels. Role-play strategies can provide high psychological fidelity for simulation-based training, and these results reinforce the potential of role-play methodologies in medical education.