This study aims to assess the influence of the EP on the technical and non-technical performance of learners during simulated situations. The present findings showed that EPs might influence the technical and non-technical performances of learners during HFS. It seemed that the EPs could exert either a positive or a negative influence on these performances. This effect appeared heterogeneous and not predictable by either the characteristics of the EPs or by their experience in simulation. However, there was a tendency for poorer performance when the facilitator was an experienced physician playing the role of a nurse. The survey highlighted a significant variability of practices and the lack of training concerning the role of the EP.
Standards of best practice for simulation have been widely reviewed and it is known that the performance and learning of participants depend on the immersion quality of a simulation scenario [8, 10]. Physical, or environmental fidelity specificallly relates to how realistically the context of the simulation-based activity simulates the actual environment in which the situation would occur in real life [8, 10]. Therefore, the use of an EP plays an important role tin maintaining this environmental fidelity and ensuring participants’ full immersion. Surprisingly, little attention has been given to the role of the EP in the literature. The current work is therefore the first to focus on the EPs and their influence on both technical and non-technical performance during HFS. EP’s profession, experience and other characteristics may play a role in the scenario that may affect the learners. Simulation instructor courses are becoming increasingly available through a variety of educational options. Setting up a simulation program, defining educational objectives for learners, the steps of building a scenario, and the key stages of a briefing and debriefing sessions are subjects that are deeply expanded through trainees [14]. With the number of fundamental steps that need to be learned, the EP and his role are most of the time vaguely explored. Previously, in a study conducted in 2015, when the top elements that potential instructors wish to learn in simulation training courses were asked, the role of the EP was considered the least important [15]. Controversially, in 2022, the respondents of our survey estimated the role of the EP as the second most difficult and mentioned that a specific EP training could be beneficial.
The EP often enriches immersive healthcare simulation sessions. According to our results, only one EP (S61), who was not a physician, had a positive influence on learners’ technical performance. Considering that the role of the EPs in all scenarios was to play the “assisting nurse”, a physician playing this role is more likely to show medical skills during the scenario than a nurse playing his/her own role. Lacking any EP-specific training, there might be some disruptive attitude of the physician playing the EP that is catched by the learner and results in disturbance of learner immediate performance. Is it inoportune initiatives, feelings of higher expectations from the EP, less fluidity in nurses’ behaviours, or the fact that the EP is already known as a real physician that are factors providing these effects on performance? There is a need for further clarification studies to explore those hypotheses. These observations reinforce the idea that an EP should ideally play his/her own profession role for more realism.
Six EP influenced the learner’s non-technical performance. Some were distractors and others were helpers. EPs with long professional experience seemed to be associated with poorer non-technical performance of learners. One might suspect that experience could come with age, and the greater the age of the EP, the greater the learner feels unconfortable with keeping the leadership, which results in a decrease in non-technical objective performance. Once again, further studies will certainly bring rational explanation to that observation as it may result in pedagogical impact and/or summative impact if simulation is becoming an assessment tool. Previous literature has shown that clinical experience is not associated with effectiveness as a simulation instructor [15, 16]. Lee et al. demonstrated that junior staff doctors felt more comfortable in HFS facilitation and similarly, years of clinical experience did not increase their comfort in teaching HFS [15]. Moreover, a relationship between teachers’ personality and teaching effectiveness has been demonstrated [17]. Personality provides a behavior that reflects human interactions, and it seems more difficult to modify an individual's technical knowledge than to help him/her express the non-technical skills. Therefore, it seems easily understable that the EPs influenced the non-technical performances more than the technical performance. Therefore, we may suggest that the performance of learners is affected not only by demographic factors such as age, gender, or experience, but also by other factors such as emotional intelligence, personality of the EP, gender mix and human interactions between both the learner and the EP [18]. Among the few studies focusing on the EP, one explored the effect of the presence of an EP on participants’ non-technical performance during simulated practice of medical crisis situations [19]. In contrast to our results, a previous study conducted by Traoré et al. reported that the presence of EPs during simulation scenarios did not seem to improve the crisis resource management skills of learners [19]. They presented a non-significant difference when comparing overall crisis resource management performance between learners who were accompanied by an EP and those who were not. These results are controversial with our findings that suggest a greater influence of the EP on non-technical performance than on technical performance. Previously, Mavis et al. evaluated the impact of standardized patients on students’ experiences by comparing faculty members and students to portray this role [20]. They demonstrated that faculty member standardized patients provided more helpful feedback to improve skills even if the students mentioned they were more intimated. Students were less anxious when the EP was a peer but they described the simulation session as less valuable [20]. According to the clinical environment, faculty members with related expertise may lead to a rich clinical experience. However, our results did not show any significant effect of the teaching status of the EPs, yet this could be due to their small number and to the diversity of EPs’ characteristics.
Strengths and Limitations
To our knowledge, this study is the first one to highlight a potential effect of the EPs on learners’ both technical and non-technical performance. While an important number of simulation sessions were reviewed (more than 300 scenarios), several limitations can be underlined. First, the effect of 19 EPs was analysed: although this number may be seen as important in terms of training and pedagogy, it is still modest regarding statistics. A larger sample size of EPs might have allowed to highlight the main characteristics that could lead to impact on learners’ performance. Second, the EPs did not facilitate an equal number of scenarios and the scenarios did not exhibit the same level of difficulty. However, the retrospective nature of the study over a period of five years could have brought heterogeneity to the EP population since EPs with different professions and backgrounds were involved. Third, no evaluation was performed after the simulation. Simulation is first a pedagogical tool. Therefore, it might be more interesting to explore the effect of some facilitation compared to others in the subsequent simulation performance of in further real performance of learners. Fourth, the simulation as a formative tool is not comparable to simulation as a summative tool for the assessment of students or professionals. The objective structured clinical examination (OSCE) as a specific simulation assessment tool shall be extensively explored for all interactions between standardized patient and student that may affect performance of the student. The impact of the success or failure on the OSCE is major for student curricula. Therefore, the impacts of uncontrolled interactions between EPs and students should not remain unexplored, to avoid the risk of the tool being discredited by students. The present study could be considered an incentive for more clarification studies to address these questions.