522655
research-article2014
NSQXXX10.1177/0894318414522655Nursing Science QuarterlyDunnington
Article
Presence with Scenario-Based High Fidelity Human Patient Simulation
Nursing Science Quarterly 2014, Vol. 27(2) 157–164 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0894318414522655 nsq.sagepub.com
Renee M. Dunnington, RN; PhD1
Abstract The aim of this grounded theory study was to explain the nature of presence among nursing students participating in scenariobased high fidelity human patient simulation. Data were derived from observations and interviews with 145 participants. Among participants, presence was found to be a multidimensional, dynamic interaction characterized by a centricity between the simulation and the natural environment. Presence, the core concept from the explanatory model that emerged from this study, is delineated in this article. Presence centricity in simulation may impact the learning experience and outcomes. These study results may support development of the educational science related to clinical simulation. Keywords high-fidelity human patient simulation, presence
In this age of technology, clinical simulation is increasingly becoming an integral component in the education of nurses and other healthcare professionals based on a myriad of professional, educational, social, economic, political, and safety factors propelling its use. High-fidelity human patient simulation (HF-HPS) offers rapidly advancing technical capabilities that afford modeling a greater variety of clinical situations. The use of simulation is making a significant contribution in the education of healthcare professionals especially for training with uncommon, inaccessible, or dangerous procedures that require competency prior to application in live patient care situations. The widespread adoption of simulation for clinical education may now have a significant impact on the development of healthcare professionals. Learning transfer from simulation to the live clinical situation also may have a significant impact on healthcare quality. The potential influence of simulation illuminates the importance of more clearly understanding the learner experience, learning outcomes, and learning transfer. This study arose from observations while facilitating learners’ participation in high-fidelity human patient simulation scenarios. Some learners displayed difficulty interacting in what they perceived to be a pretend or simulated situation. Others seemed to readily suspend disbelief accepting and interacting in the situation as if it were real. During debriefings following simulations, students also described variations in the ways that they engaged and interacted in the simulation as well as variations in perceived learning outcomes. It became evident that the conflict between the real and the pretend associated with simulation challenged students to make choices about their presence in simulation.
Furthermore, discussions with other faculty members also revealed a lack of clear understanding concerning variations in learner engagement and interaction with scenario-based HF-HPS and concerns for the impact on learning outcomes. Therefore the purpose of this study was to explain the basic social process of presence among nursing students participating in scenario-based HF-HPS and the potential impact of presence on learning outcomes. The ultimate goal of the study was to develop an explanatory model of presence in the context of scenario-based HF-HPS. From the emergent model, the nature of presence in the context of scenariobased HF-HPS is described here. Scholarship on the nature of presence in the context of the nurse-patient interaction, despite variability among conceptualizations, consistently has identified the attributes of engagement, attentiveness, intentionality, immersion, therapeutic agency, connection, and the sense of being with in relation to others (Parse, 1998; Paterson & Zderad, 1976; Watson, 2007). More recently Kostovich (2012) has characterized nursing presence as a “multidimensional unified whole fluidly existing in the cognitive, affective, behavioral, and spiritual… domains” (p. 169). Presence also has been shown to have a positive influence on task performance and other learning outcomes in virtual reality types of learning (Witmer & Singer, 1998; Zhao, 2003). However, scenario-based HF-HPS 1
Associate Professor, Capital University, Columbus, Ohio
Corresponding Author: Renee M. Dunnington, Capital University, 1 College and Main St., Columbus, OH 43209. Email: [email protected]
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is a “mixed reality” form (Milgram & Kishino, 1994) that comingles stimuli from the natural environment with elements of the virtual context (Zhao, 2003). Scenario-based HF-HPS requires role play interaction by participants with the virtual context comprised of stimuli from the computerized mannequin, integrated monitor output, and dynamic, scripted scenario enactment representing a healthcare situation. HF-HPS would be classified, then, as an augmented virtuality according to Milgram and Kishino’s (1994) virtuality continuum. Scenario-based HF-HPS differs from other virtual contexts in that the stimuli of the natural environment pose greater competition with the stimuli from the environment of the simulation compared to other virtual contexts where sensory awareness of the natural environment might be more easily excluded. Presence in the context of HF-HPS is little understood. This is among the first studies in nursing concerning presence in scenario-based high-fidelity human patient simulation. In a general sense, presence is a multidimensional state of being in interaction in the real world. Presence is epiphenomenal, a state of interaction resultant from the convergence of sensation, perception, focus, attention, cognition, engagement, and action. As an interactive and highly-situated state of being in interaction, presence has been defined in various contexts and in disciplinary specific ways. In the context of human to human, embodied interaction, presence has been defined in social psychology as the sensory awareness of the other that triggers a psychological response that frames human conduct according to the perceived identity and response of the other (Goffman, 1959). In virtual contexts, interaction is mediated by technology. Presence in the virtual context has been defined as the subjective sense of being there, (Minsky, 1980, p. 48) and as an “experience of being in one place or environment, even when one is physically situated in another” (Witmer & Singer, 1998, p. 225). In the context of virtual-type simulation, presence includes the dimension of immersion where “the virtual environment becomes the dominant environment perceived and where participants respond more to events in the simulation rather than in the natural world (Slater & Wilbur, 1997). In nursing, presence has been defined in the context of the caring relationship between nurse and patient (Parse, 1998; Patterson & Zderad, 1976; Watson, 2007). Definitions in nursing refer to presence as a state of being with another with the added dimensions of sensitivity to human needs, as well as the dimensions of a therapeutic and agentic consciousness. The nature of presence in the context of HF-HPS had not been defined prior to this study. At the time of this study, a literature review revealed only one study concerning factors that might influence presence in high-fidelity human patient simulation (Dieckmann, Manser, & Wehner, 2003). This study, presented at the International Society for Presence Research, 6th Annual International Workshop on Presence, involved six anesthesiologist participants in clinical simulation scenarios. Presence was found to be influenced by user and scenario-related factors. User
factors included emotions, anticipation, and group dynamics. Scenario factors included technical, task, role, meta view, and action features. Based on these findings, the researchers constructed a beginning model of factors that may influence the experience of presence in this study. Yet the nature of presence in the context of HF-HPS was not reported.
Method As yet, little is known about presence in the context of scenario-based HF-HPS, an augmented virtuality form of simulation. This was the first nursing study to examine the nature of presence in relation to HF-HPS. Based on the state of knowledge regarding presence in this context and on the complexity of presence as a process of social interaction, a second generation grounded theory approach was used for this inquiry (Charmaz, 2006). Second generation grounded theory approaches adopt the classic methodology first put forth by Glaser and Strauss (1967) and Glaser (1978) including the process of simultaneous data collection, analytic coding, constant comparative analysis, iterative theoretical sampling, and theory construction. Yet, second generation grounded theory methodology has an interpretivist stance aimed at understanding a co-construction of reality that is assumed to be multiple, complex, relative, and situated in context (Charmaz, 2006; Clarke, 2005). Therefore, a second generation grounded theorist may more actively seek the complexity (Clarke, 2005) of phenomena under study in the research process. Second generation grounded theorists also account for an assumption of the interaction of the researcher and the research process on the data and on the theory construction by engaging reflexivity throughout the research process (Charmaz, 2006; Clarke, 2005). For this study, the second generation grounded theory approach most aligned with Charmaz (2006) was utilized. The methodology was used to construct a model of the nature and determinants of presence as defined by nursing student participants in scenario based HF-HPS as well as a theorization of how presence may influence learning outcomes. The core concept of presence from the emergent model derived from this study is delineated in this report.
Ethical Considerations Institutional review boards at each participating simulation center and academic institution gave approval prior to the start of this study. Conduct of this study was guided by the principles of informed consent as well as dynamic and emergent, voluntary participation. Since nursing students and experienced nurse learners were considered captive groups, potential participants were informed that the study was not an academic or a work requirement and assured that participation would not influence their evaluation or standing. In appreciation of the time required for interviews, remuneration was provided. The remuneration was of low monetary value to guard against undue influence.
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Sampling The sample was drawn from two Midwestern simulation centers having academic and hospital affiliations. Consistent with established analytics of grounded theory methodology, an a priori specification of an ultimate sample size was avoided. The criterion for initial inclusion in the study was that participants were late term junior or first term senior level, pre-licensure, traditional baccalaureate nursing students participating in a scenario-based, high fidelity human patient simulation experience as a course requirement. At the outset of the study, a purposive sample of 30 traditional baccalaureate nursing students was recruited. Next a theoretical sample of 32 second degree pre-licensure nursing students was recruited. This sampling provided for a comparison on themes concerning dimensions of life experience, academic development, age, and maturity. As the study progressed, based on other emerging themes and comparative analyses, a sample of 30 experienced registered nurses and 20 academic faculty members and hospital-based nurse educators were invited to participate. To densify the dimensions on categories, two simulation lab directors and one nursing administrator were recruited to participate. The criterion for comparative and theoretical sampling also included that interviewees were either participants or facilitators of the simulations or were administrators having supervisory or budgetary responsibility for the simulation laboratory facilities. The professional, registered nurses participated in a simulation as a job requirement for annual competency training. The theoretical sampling plan was aimed at de-centering the primary participants from an assumed, all knowing position and at providing opportunity for less salient or diverse elements to be revealed. Finally, for stabilization and verification of concepts and linkages in the emergent model and in search of discrepant or disconfirming cases, an iterative sampling return to the primary sample was undertaken. In this sampling, 30 more traditional baccalaureate nursing students were invited to participate. At this point, data saturation and density of concepts were evident.
Data Collection A total of 36 simulations were observed. All simulations were two- hour learning experiences comprised of a preparatory assignment, lab orientation, preplanning session, 60-90 minute simulation scenario and a 20-30 minute debriefing session. The simulations were dynamic, scenario-based simulations concerning declining patient health status (post-surgical hemorrhage, acute myocardial infarction, respiratory failure, septic or cardiogenic shock), and requiring either an urgent intervention or emergency code resuscitation. The design of all simulations included the use of the METI® prehospital model human patient simulator. Observations of the simulations were conducted through a one-way glass window. Two of the simulations were
observed from the side of the room when a one-way window was unavailable. Simulations also were digitally video-recorded for later analysis. A process of descriptive, focused, and selective observation was conducted. A semistructured observation framework was utilized for focused and selective observations to sensitize the observations to relevant elements, but also to allow for emergent elements in the observation. Observation categories included: sensory-perceptual, psychological, actional, processual, and consequential aspects. Participants were informed that they would be observed but were unaware of the observation framework. Jottings were recorded during the simulation encounters and detailed field notes and video transcriptions were completed within 24 hours following the simulation encounters. All participants completed semi-structured group interviews during the debriefing sessions. In-depth, individual interviews were conducted with 94 participants. Individual interviews occurred within 30 minutes to 48 hours following the simulation encounter and lasted 30 to 60 minutes. Timing of the interviews was aimed at the avoidance of significant memory decay among participants. All interviews were digitally audio-recorded and transcribed verbatim. The initial interview prompts were structured around concepts related to presence drawn from the literature to assure elucidation of salient and thematic elements. Semi-structured interviewing also allowed for emergent and non-salient aspects to come to light. Sample prompts included: (a) How would you describe your experience in the simulation? (b) Tell me what you were aware of during the simulation. (c) Describe your interaction during the simulation. Throughout the study, interview prompts were narrowed, broadened, or revised to focus around categories that emerged for theoretical insight (Charmaz, 2006).
Analysis All observations were transcribed and coded in their entirety. A professional transcription company reporting 98-99% reliability transcribed the interviews. All interview transcripts were reread simultaneously with the recordings for initial coding. Classic Glaserian coding (Glaser, 1978) was employed through an iterative process of line by line, open coding, followed by comparative analysis, theoretical sampling, and selective coding. This was followed again by comparative analysis, theoretical sampling, and theoretical coding. As theoretical codes stabilized, the return to sampling again from the primary sample of nursing students provided validation. A preliminary model emerged. The final level of analysis was directed at condensing concepts and raising the level of abstraction in the model. Concepts and linkages from the model were used in the last round of sampling during interviews for stabilization, verification, and validation. Memos were written throughout the analytic process to encourage theoretical sensitivity, to raise the level of
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abstraction, and to generate interconnections between codes and categories (Charmaz, 2006).
Rigor To achieve prolonged engagement, the study was conducted until data saturation was reached which also was a full academic year. The length of the individual interviews was significant in relation to the length of the simulation experience. The interview process was viewed as an active and non-neutral process that would produce a co-constructed (Charmaz, 2006) text. Reflexive journaling was used to acknowledge and minimize a sensitized imposition on the data and analysis (Charmaz, 2006) with particular concern for preconceptions around the concept of presence from the literature and from other contexts. The use of triangulation of observation and interview methods aimed to avoid decontextualized data collection (Charmaz, 2006). Triangulation through sampling from different institutions and comparison between sampling groups further enhanced confirmability. Member checks during validation interviews also enhanced confirmability. A significant audit trail of 130 audio files and 36 video files provided dependability of the study data. The rich yield of narrative transcription text provided the evidentiary adequacy of this study and supported the use of rich quotation passages from participants that reflected the essence of the nature of presence in HF-HPS reported in this study. The limitations and reductions of transcription and coding as well as the potential for researcher interactions on observation and interview data may have influenced the results of this study, despite all of the measures for protection undertaken against these threats. It is also possible that a broader range of participants and simulation contexts could have yielded additional or differing findings.
Findings The final sample consisted of 145 participants. The age range of students was between 20 and 36 years. The range of age among registered nurses, faculty members, and administrators was between 23 and 60 years. Gender and ethnic patterns in the sample were similar to the national percentages among the registered nurse populations reported by the most recent United States Department of Health and Human Services Survey of the Registered Nurse Population (2010).
Centering Presence Students and professional nurse participants described and were also observed having multidimensional and dynamic states of presence as they interacted in simulation scenarios. These states were most characterized by a centricity. Centricity refers to the locus of the state of being in interaction based on the salience of perception of stimuli from the simulation environment in relation to the natural environment. Two primary
states of presence centricity were evident: endocentric presence and exocentric presence. Participants seemed to center their presence primarily inside the simulation scenario (endocentricity) interacting fully in the simulation environment or outside the scenario interacting more with the natural or proximal environment (exocentricity). Presence was a fluid and dynamic process that occurred throughout the simulation experience. Presence centricity conditioned meaning and mediated interaction in the situation influencing both experience and action. Endocentric Presence. Many nursing students became drawn into the situation in such a way that the simulation situation overtook their focus and attention. The natural environment faded in the background. Their senses were engaged by the stimuli and interactions of the simulation scenario. They became cognitively involved and enacted a care-giving role in an embedded psychological state of being, as if involved in a real patient care situation. As one faculty member participant observed, It seems like it is all about being drawn into the situation. The situation overtakes them. Then it is like they are there – in the real. It is like they are involved and immersed into it. Their focus is really [emphasis] on the patient and on what’s happening with them, and what they should do about it.
Another faculty member participant stated, “It is like they become tunnel-visioned on the patient and everything else around them is just gone.” Thus, endocentric presence in HF-HPS is conceived as a dominant perception of being and enacting the self as if in a role in the real patient care situation represented by the simulation. Endocentric presence is indicated by a state of immersion (sensory-perceptual envelopment) and involvement (focus/attention/action) in the simulation situation similar to Witmer and Singer’s (1998) description of presence in computer simulations. One student’s comment reflects the endocentric state of being. Note in the next passage the dominance of the patient situation over the proximal environment and the perception of being there in a real patient care circumstance. Well, the patient was my main concern. At first it was pain; it was hurting her and that was my concern. Then the second thing, it was the hemorrhage and we had to try to keep the patient calm while we had to deal with the blood transfusion. I felt like a nurse. It was like you see one thing and the next in the simulation and you focus on that and do something to fix it. You kind of forget the fake picture. Do you know what I mean? You get involved in the situation like it is real. You don’t even notice other things around you while you are involved in it, you know?
Exocentric Presence. A second state of presence also emerged where students were interacting with the simulation; yet, they
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Dunnington remained acutely aware of the natural surroundings as if they were being watched and made to perform. Their focus and attention remained more on the outside of the scenario situation. Their interaction displayed a degree of self consciousness, dismissiveness, and disconnection. They stood back and watched almost as if uncomfortably waiting to be forced into becoming involved in the situation. One faculty member participant described this state of being in the following way. They don’t feel that it is real because they are being forced into talking to a dummy. You can really see if they are not engaged in the simulation. They start having their own personal conversations socially outside of the situation. They are like outside the scenario. They are not immersed and not present in it. In fact they act even a little bored. Or they are dismissive when they do something wrong and they say, “Oh well, it isn’t real anyway.” They go through it like it is just pretend [and has no consequence.]
Based on emergent patterns in this study, exocentric presence is conceived as a dominant state of being in and interacting with the natural environment where the meaning of the simulation environment is perceived strongly as artificial. The participant enacts the role from an outsider perspective disconnected from the simulated patient-care situation. Their interactions and actions with the simulation are thereby constrained by the meaning of the artificial environment and the dominance of perceived stimuli of the natural environment. Students similarly characterized their experience in HF-HPS as a state of being either inside the simulation situation or on the outside of the situation. The student here recounted a more exocentric state of being in the simulation. Notice in this narration that the student was highly aware of the artificiality of the simulation activity and was concerned with the observers and facilitators in the proximal, natural environment. The dominance of the natural environment seemed to mediate on the student’s perception, actions, and experience. I felt so awkward. I don’t know if it’s just because of in my mind, I know it’s fake. I guess I just felt like I was outside like watching everybody inside paying attention and attending to it. It felt unnatural almost. I know I was busy with stuff, like just doing the tasks, like I was going through the motions, like it would be scripted. I wasn’t really worried about the patient or that I am going to hurt anything. I was just thinking about the people in the booth and the teacher watching and it just doesn’t make it seem real to me at all. It is just a weird psychological thing, you know?
Shifting Presence Bicentric Presence. While participants did describe and were observed in discrete states of endocentric and exocentric presence interactions, the experience of the majority of students in this study can be interpreted as being in a more bicentric state of presence. During bicentric presence interactions, students
were predominantly aware and interacted in one environment, while still maintaining awareness and interaction with the other. Bicentric presence in HF-HPS is conceptualized here as a state of being in which both the simulation and the natural environment are perceived and experienced dynamically at varying degrees of intensity. In this state of being, the degree of perception and action were generally centered with greater intensity in one environment or the other. There was a degree of overtake by the simulation environment; yet, the participant remained aware of the primary environment to some degree. This is consistent with the simultaneous experience of both a natural and a virtual environment that has been described of presence in other types of virtual simulation environments (Ijsselsteijn, 2002). One student described the experience of bicentricity in HF-HPS in this way. “Yea, the simulation was real and not real enough at the same time. I felt right in-between. Yes, right in-between something real and not real at the same time. Like one foot in and one foot out.” Another student also described a bicentric state of being in simulation where starting from an endocentric position, her awareness of the natural environment, exocentricity, became salient. I started out very focused on the situation. I was working with the primary nurse to figure out how we should get things accomplished. But then, sometimes, I feel, just like laughing like, this isn’t real and I feel like I pulled right of the situation.
Another student’s reflection also illustrates the dynamic of bicentric presence. She described how the stimuli from the patient condition in the simulation overtook her from a more exocentric state to a more endocentric state of being. It was kind of an odd experience. Like at first you feel silly taking it seriously because he isn’t real. You feel at first like you are just yourself pretending. But at the same time, once he started to decline and he went into V-fib, I kind of had this sense of urgency to fix it. I got nervous and the adrenalin was pumping. Even though I knew he wasn’t a real patient, it got so nerve wracking because you kind of put yourself in the real scenario. It was this sense of urgency that came over me that kind of surprised me. It kind of put me there like in a real life situation. I had the sense of fear that the patient would be dying – that sense of fear that I would have if it were real.
Breaks in Presence. As described by participants, bicentric presence is a dynamic state in which the student moves between the proximal and the simulation environments. At times this was a gradual shift from one environment to the other where students were drawn in by the situation from an exocentric state of being on the outside of the situation to an endocentric state of being on the inside of a seemingly realistic patient situation represented in the simulation. Yet, in the example of the student that described a sense of being “pulled out of the situation” the perceptual and attentional shifting (Ijsselsteijn, 2002) can also be more fully in or out of the simulation to more discrete states of endocentricity
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or exoentricity. This abrupt shift in presence is aligned with the concept of breaks in presence originally described by Slater and Steed (2000). This occurs when participants in simulation stop attending to the stimuli of the virtual environment and attend more to the stimuli from the natural environment. Breaks in presence seemed at times facilitative and at other times seemed counterproductive to maintaining or restoring an endocentric state of being relative to the HF-HPS environment among study participants. For example, at times students participating in HF-HPS are called upon to enact the role of the nurse requiring skills for which they may or may not have full knowledge or competency to perform. It is in this case that breaks in presence most often occurred. These students chose to draw on the natural environment by asking the instructor or the facilitator for assistance. At other times, instructors broke presence by interrupting the scenario from the outside to draw students’ attention to a cue in the simulation, to assist in task performance, or to prompt clinical reasoning regarding the patient situation. The examples that follow illustrate that a student-initiated break in presence could be facilitative; whereas, an instructor-initiated break in presence seemed counterproductive. This student described a situation in which the break in presence facilitated endocentric presence in the simulation. Sometimes we stopped to ask the teacher a question. I remember that I kind of stopped and turned to her and asked the question because she was sitting right out there, but not really. But then I went right back into the situation doing something with the patient and I was really into it again. Sometimes you just need to get a thing that you don’t know answered so you can go on in the situation.
Another student also explained the facilitative nature of a student initiated break in presence. Well sometimes it was necessary to ask a question because if we didn’t, we would have been stumbling or just frozen. It is like you just put it on pause to ask a question and then un-pause and start up again right from where you were.
However, a break in presence also can be counterproductive. This student described a state of moving to a completely exocentric state of being in the simulation when the instructor initiated a teaching moment in the simulation. Her words conveyed the sense that part of the learning experience was lost by this shift. When she jumped in and started doing things in the simulation and talking about things in the simulation, it was pretty much over for me. I would say that it just broke me out of the simulation and now it was just a lab situation again and it just turned into a teaching session, again. That was OK, but if the point was for us to go through a realistic patient care situation, it was all over after that.
Nature of Presence in HF-HPS Three presence states were evident through the observations and the interviews of the participants. Dimensions of these states also clearly emerged from these data. Endocentric presence is characterized by a sense of “being there” or “putting oneself” in the framing of a real patient care situation. Once there, those that were endocentrically present in HF-HPS were observed to have high levels of immersion, focus, and attention and to be less influenced by distractions in the surrounding natural environment. This seemed to foster high cue sensitivity and a sense of agency in the patient care situation. Endocentric presence also was characterized by emotional responses related to the care situation. These included a sense of urgency, nervousness, fear, or compassion. Participants experiencing an endocentric presence perceived a connection to the patient situation and felt a sense of responsibility and accountability for the patient status in the simulation as can be seen in the responses of participants. In contrast, participants that experienced a more exocentric presence framed themselves outside the patient care situation and described resisting or feeling forced into being in the situation. Their focus and attention appeared to be more on others in the natural environment and on the self as a performer in the situation. These participants exhibited reduced cue sensitivity and higher levels of distractibility. They perceived the situation as artificial and inconsequential. This fostered low perceived levels of agency, emotion, and accountability. Bicentric presence was observed to be the most common presence interaction among participants in HF-HPS. This state of being was characterized by the participant’s perception of and interaction with both the natural and the simulation environment at some level of salience of one over the other. Bicentricity was further characterized by a salience of presence in which either endocentricity or exocentricity was dominant and as Ijsselsteijn (2002) has described in other virtual contexts, where participants were always aware of the other environment often experiencing shifting attention (Ijsselsteijn, 2002) between the proximal and the simulation environment.
Discussion Presence has received wide attention across disciplines for its central importance to the participant’s experience with other forms of virtual reality simulation and the likely impact on task performance or other outcomes. The nature of presence in HF-HPS described in this study is consistent with and supports evolving conceptualizations of presence in related virtual contexts. Presence among participants in this study was multidimensional and complex. The dimensions of presence included immersion and engagement as has been found in other virtual simulation environments (Wither & Singer, 1998; Slater & Wilbur, 1997). As others have also reported in virtual simulations (Ijsselsteijn, 2002; Herrera, Jordon & Vera, 2005; Slater & Steed, 2000), presence in
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Dunnington HF-HPS was characterized in this study by perception of reality, suspension of disbelief, cognition, action, agency, and psychological responses to the simulated patient-care situation. Based on the results of this study, the nature of presence in the context of interaction mediated by HF-HPS is conceptualized as a sensory-perceptual, cognitive, psychological and actional engagement in an experience where the stimuli of the simulation environment immerses the participant in artificial representation of a natural human phenomenon, and where the individual perceives the experience at a level of realism and salience as an agentic, caring self. Presence is further conceptualized in the context of HF-HPS as a dynamic state of being in which individuals experience centricity between the simulation environment and the natural surrounding environment, and in which participants perceive the stimuli from one environment to be salient over the other. The centricity of presence has primary domains of either exocentricity or endocentricity relative to the simulation environment. As a dynamic state of being, participants also may be drawn inside or outside of the simulation situation (breaks in presence) or may experience both the simulation and the natural environment simultaneously (bicentricity) at varying degrees of salience. The concept of presence centricity used here is somewhat related to similar terms used in the context of other virtual environments. Slater and Wilbur (1997) and Salzman, Dede, and Loftin (1999) refer to the terms egocentric and exocentric to define frames of reference in the graphic design of virtual display environments. In their work, these terms refer to the human - computer interface that provides the view that places the user’s perspective on the inside or the outside of virtual environment. However, presence centricity conceptualized in the context of HF-HPS is differentiated here. The concepts of endocentrism and exocentrism in relation HF-HPS, a mixed reality form, refer to the perceived salience of the simulation environment over the natural environment as they co-mingle. The virtual aspect of HF-HPS co-mingles human and nonhuman elements among the stimuli and cues of the scenario enactment. Consequently, participants become immersed, engage, and interact on the inside or the outside of the simulation scenario environment by their own volition. Earlier work on presence in other disciplines has conceived presence existing in exclusive modes between the natural and virtual environments. In this study, the concept of centricity of presence was shown instead to be a dynamic state of being in which the stimuli of either the natural environment or the simulation environment is salient (endocentricity versus exocentricity) but where both environments may be experienced simultaneously (bicentricity). This conceptualization supports Ijsselsteijn’s (2002) findings of presence intensity. The findings of this study are also consistent with the concept of breaks in presence that have been identified in virtual simulation environments. Breaks in presence are the dynamic states of being present in simulation where the participant abruptly stops responding to the virtual stimuli and instead immerses in the stimuli of the natural proximal environment
(Slater & Steed, 2000). Breaks in presence also were noted in this study and were typically invoked by distraction from the natural, proximal environment or by the interaction of the facilitator of the simulation. The finding of breaks in presence further supports the conceptualization of presence in HF-HPS as a dynamic state of being. HF-HPS, an augmented virtuality (Milgram & Kishino, 1994), represents a different socio-technical milieu than other virtual forms of simulation. By nature, this hybrid form of simulation mixes the natural environment (human interactions in the patient care situation) and the virtual environment (artificial mannequin patient, computer displays, and scenario enactment) involving a participant simultaneously being and interacting in both the natural and the virtual environments. Natural human interactions between participants are integral to the enactment of the simulation. Facilitators are required for the implementation of the scenario states and stimuli. Therefore, the proximal and the simulation environments co-exist and may mediate on the participant experience in various ways. The increasing use of technology in nursing education has led to questions regarding the potential for presence in the context of virtual reality and HF-HPS (Condon, 2013). Results of this study suggest that states of presence do exist among participants in scenario-based high fidelity simulation. This study also demonstrated that an immersive, endocentric presence is clearly inducible with scenario-based high fidelity human patient simulation. The nature of endocentric presence experienced by participants in this study displayed attributes both similar and different from presence as it has been described in the natural context of nurse-patient interactions. The findings of this study then, add information to the nursing literature on presence as specified with the attributes of engagement, attentiveness, intentionality, immersion, therapeutic agency, connection, and the sense of being with articulated by Parse (1998), Paterson and Zderad, (1976), Watson (2007), and Kostovich (2012) who wrote that nursing presence was a “multidimensional unified whole fluidly existing in the cognitive, affective, behavioral, and spiritual…domains” (p. 169). The endocentric state of presence in the context of the simulated nurse-patient interactions in HF-HPS displayed similar attributes to presence in natural nurse-patient interactions. Participants in this state of being described the experience of being immersed in a perceived real situation with attributes of attention, engagement, involvement, cognition, therapeutic agency, and affective responses. Presence in the context of HF-HPS was experienced as a mediated state of being in interaction. Participants seemed to engage more with a perceived situation rather than being engaged in interaction in the sense of being with another person. They seemed to perceive the patient as a rather disembodied other, yet projecting themselves forward into an imagined nurse- patient interaction. While nursing students in this study experienced affective responses, presencing more with a perceived situation lacked the interpersonal connection and mutual experience of intimacy, sensitivity, or commitment of
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the affective and spiritual domains that have so often been attributed to presence in the therapeutic-caring relationship of the natural nurse-patient interaction. Despite this difference, an endocentric presence in the technology- mediated situation of HF-HPS seemed to offer as Kiran (2012) has described an experience of the actuality of the simulated-patient situation and as a potentiality of the real patient situation. In this way, as Condon (2013) has noted, a technology-mediated presence as in the context of HF-HPS is differentiated from presence in natural nursepatient interactions.
Conclusion Presence is a means by which participants experience reality in social interactions. The close connection with reality that presence affords in simulation makes presence a potentially important consideration for research concerning clinical simulation. This study makes a foundational contribution to nursing regarding an understanding of the nature of presence related to the context of HF-HPS. Theorizing from the extant state of knowledge on presence (Kostovich, 2012; Parse, 1998; Paterson & Zderad, 1996; Watson, 2007), and from the larger presence model generated from this study, pedagogic support of endocentric presence in HF-HFPS may lead to more educative learning outcomes that may transfer to the real clinical situation. Further research to examine the relationship between presence and learning outcomes also may support development of the educational science related to clinical simulation in healthcare and may further support the development of healthcare professionals. Scenario-based high-fidelity human patient simulation is a technology and a technique that is increasingly authentic having the potential to amplify and to reveal a variety of natural clinical patient care situations. Simulation may invoke the imaginative capacities of participants allowing them to experience a centricity of presence as if in the real clinical situation. It is the connection to the experience of reality that presence affords in simulation that bears its significance. Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the authorship and/or publication of this article.
Funding The authors received no financial support for the authorship and /or publication of this article.
References Charmaz, K. (2006). Constructing grounded theory: A practical guide through qualitative analysis. Los Angeles: Sage. Clarke, A.E. (2005). Situational analysis: Grounded theory after the postmodern turn. Thousand Oaks: Sage. Condon, B. B. (2013). The present state of presence in technology. Nursing Science Quarterly, 26(1), 24-28.
Dieckmann, P., Manser, T., & Wehner, T. (2003, October). Presence and high fidelity patient simulators in anaesthesiology: Influences derived from interviews and questionnaires. Proceedings of PRESENCE 2003 the 6th Annual International Workshop on Presence. Aalborg Denmark. Retrieved from http://www.temple.edu/prev-conferences/proceedings/2003/ Dieckmann,Manser,Wehner.pdf Glaser, B. G. (1978). Theoretical sensitivity. San Francisco: Sociology Press. Glaser, B., & Strauss, A. (1967). The discovery of grounded theory: Strategies for qualitative research. New Brunswick: Aldine Transaction. Goffman, E. (1959). The presentation of self in everyday life. Garden City, NY: Anchor. Herrera, G., Jordon, R., & Vera, L. (2005, September). Agency and presence: a common dependence on subjectivity? Proceedings of PRESENCE 2005: The 8th Annual International Workshop on Presence. London. Retrieved from www.temple.edu/ispr/ prev-conferences/proceedings/2005/Herrera,Jordan,Vera.pdf Ijsselsteijn, W. (2002). Elements of a multi-level theory of presence: Phenomenology, mental processing and neural correlates. Proceedings of PRESENCE 2002: The 5th Annual International Workshop on Presence. Retrieved from http://www.temple. edu/ispr/prev-conferences/proceedings/2002/Ijsselsteijn.pdf Kiran, A.H. (2012). Technological presence: Actuality and potentiality in subject constitution. Human Studies, 25, 77-93. Kostovich, C.T. (2012). Development and psychometric assessment of the presence of nursing scale. Nursing Science Quarterly, 25(2), 167-175. Milgram, P., & Kishino, F. (1994). A taxonomy of mixed reality visual displays. IEICE: Transactions on Information Systems, 77, 1321-1329. Minsky, M. (1980). Telepresence. Omni, 2, 45-51. Parse, R. R. (1998). The human becoming school of thought. Thousand Oaks, CA: Sage Publications. Paterson, J. G., & Zderad, L. T. (1976). Humanistic Nursing. NY: John Wiley & Sons. Salzman, M. C., Dede, C, & Loftin, R.B. (1999). VR’s Frames of reference: A visualization technique for mastering abstract multidimensional information. Proceedings of the SIGCHI Conference on Human Factors in Computing Systems: The CHI is the Limit, pp. 489-495. NewYork: ACM Press Slater, M., & Steed, A. (2000). A virtual presence counter. Presence: Teleoperators and Virtual Environments, 9(5), 413-434. Slater, M., & Wilbur, S. (1997). A framework for immersive virtual environments (FIVE): Speculations on the role of presence in virtual environments. Presence, Teleoperators and Virtual Environments, 6(6), 603-616. U.S. Department of Health and Human Services (2010). The Registered Nurse Population. Retrieved from bhpr.hrsa.gov/ healthworkforce/rnsurveys/rnsurveyfinal.pdf Watson, J. (2007). Nursing: Human science and human care – A theory of nursing. Boston: NLN Press, Jones and Bartlett. Witmer, B. G., & Singer, M. J. (1998). Measuring presence in virtual environments: A presence questionnaire. Presence, Teleoperators and Virtual Environments. 7, 225-240. Zhao, S. (2003). “Being there” and the role of presence technology. In G. Riva, F. Davide & W. A. Ijsselsteijn (Eds.), Being there: Concepts, effects and measurements of user presence in synthetic environments (pp 137-145). Amsterdam: IOS Press.
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research-article2014
NSQXXX10.1177/0894318414522655Nursing Science QuarterlyDunnington
Article
Presence with Scenario-Based High Fidelity Human Patient Simulation
Nursing Science Quarterly 2014, Vol. 27(2) 157–164 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0894318414522655 nsq.sagepub.com
Renee M. Dunnington, RN; PhD1
Abstract The aim of this grounded theory study was to explain the nature of presence among nursing students participating in scenariobased high fidelity human patient simulation. Data were derived from observations and interviews with 145 participants. Among participants, presence was found to be a multidimensional, dynamic interaction characterized by a centricity between the simulation and the natural environment. Presence, the core concept from the explanatory model that emerged from this study, is delineated in this article. Presence centricity in simulation may impact the learning experience and outcomes. These study results may support development of the educational science related to clinical simulation. Keywords high-fidelity human patient simulation, presence
In this age of technology, clinical simulation is increasingly becoming an integral component in the education of nurses and other healthcare professionals based on a myriad of professional, educational, social, economic, political, and safety factors propelling its use. High-fidelity human patient simulation (HF-HPS) offers rapidly advancing technical capabilities that afford modeling a greater variety of clinical situations. The use of simulation is making a significant contribution in the education of healthcare professionals especially for training with uncommon, inaccessible, or dangerous procedures that require competency prior to application in live patient care situations. The widespread adoption of simulation for clinical education may now have a significant impact on the development of healthcare professionals. Learning transfer from simulation to the live clinical situation also may have a significant impact on healthcare quality. The potential influence of simulation illuminates the importance of more clearly understanding the learner experience, learning outcomes, and learning transfer. This study arose from observations while facilitating learners’ participation in high-fidelity human patient simulation scenarios. Some learners displayed difficulty interacting in what they perceived to be a pretend or simulated situation. Others seemed to readily suspend disbelief accepting and interacting in the situation as if it were real. During debriefings following simulations, students also described variations in the ways that they engaged and interacted in the simulation as well as variations in perceived learning outcomes. It became evident that the conflict between the real and the pretend associated with simulation challenged students to make choices about their presence in simulation.
Furthermore, discussions with other faculty members also revealed a lack of clear understanding concerning variations in learner engagement and interaction with scenario-based HF-HPS and concerns for the impact on learning outcomes. Therefore the purpose of this study was to explain the basic social process of presence among nursing students participating in scenario-based HF-HPS and the potential impact of presence on learning outcomes. The ultimate goal of the study was to develop an explanatory model of presence in the context of scenario-based HF-HPS. From the emergent model, the nature of presence in the context of scenariobased HF-HPS is described here. Scholarship on the nature of presence in the context of the nurse-patient interaction, despite variability among conceptualizations, consistently has identified the attributes of engagement, attentiveness, intentionality, immersion, therapeutic agency, connection, and the sense of being with in relation to others (Parse, 1998; Paterson & Zderad, 1976; Watson, 2007). More recently Kostovich (2012) has characterized nursing presence as a “multidimensional unified whole fluidly existing in the cognitive, affective, behavioral, and spiritual… domains” (p. 169). Presence also has been shown to have a positive influence on task performance and other learning outcomes in virtual reality types of learning (Witmer & Singer, 1998; Zhao, 2003). However, scenario-based HF-HPS 1
Associate Professor, Capital University, Columbus, Ohio
Corresponding Author: Renee M. Dunnington, Capital University, 1 College and Main St., Columbus, OH 43209. Email: [email protected]
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is a “mixed reality” form (Milgram & Kishino, 1994) that comingles stimuli from the natural environment with elements of the virtual context (Zhao, 2003). Scenario-based HF-HPS requires role play interaction by participants with the virtual context comprised of stimuli from the computerized mannequin, integrated monitor output, and dynamic, scripted scenario enactment representing a healthcare situation. HF-HPS would be classified, then, as an augmented virtuality according to Milgram and Kishino’s (1994) virtuality continuum. Scenario-based HF-HPS differs from other virtual contexts in that the stimuli of the natural environment pose greater competition with the stimuli from the environment of the simulation compared to other virtual contexts where sensory awareness of the natural environment might be more easily excluded. Presence in the context of HF-HPS is little understood. This is among the first studies in nursing concerning presence in scenario-based high-fidelity human patient simulation. In a general sense, presence is a multidimensional state of being in interaction in the real world. Presence is epiphenomenal, a state of interaction resultant from the convergence of sensation, perception, focus, attention, cognition, engagement, and action. As an interactive and highly-situated state of being in interaction, presence has been defined in various contexts and in disciplinary specific ways. In the context of human to human, embodied interaction, presence has been defined in social psychology as the sensory awareness of the other that triggers a psychological response that frames human conduct according to the perceived identity and response of the other (Goffman, 1959). In virtual contexts, interaction is mediated by technology. Presence in the virtual context has been defined as the subjective sense of being there, (Minsky, 1980, p. 48) and as an “experience of being in one place or environment, even when one is physically situated in another” (Witmer & Singer, 1998, p. 225). In the context of virtual-type simulation, presence includes the dimension of immersion where “the virtual environment becomes the dominant environment perceived and where participants respond more to events in the simulation rather than in the natural world (Slater & Wilbur, 1997). In nursing, presence has been defined in the context of the caring relationship between nurse and patient (Parse, 1998; Patterson & Zderad, 1976; Watson, 2007). Definitions in nursing refer to presence as a state of being with another with the added dimensions of sensitivity to human needs, as well as the dimensions of a therapeutic and agentic consciousness. The nature of presence in the context of HF-HPS had not been defined prior to this study. At the time of this study, a literature review revealed only one study concerning factors that might influence presence in high-fidelity human patient simulation (Dieckmann, Manser, & Wehner, 2003). This study, presented at the International Society for Presence Research, 6th Annual International Workshop on Presence, involved six anesthesiologist participants in clinical simulation scenarios. Presence was found to be influenced by user and scenario-related factors. User
factors included emotions, anticipation, and group dynamics. Scenario factors included technical, task, role, meta view, and action features. Based on these findings, the researchers constructed a beginning model of factors that may influence the experience of presence in this study. Yet the nature of presence in the context of HF-HPS was not reported.
Method As yet, little is known about presence in the context of scenario-based HF-HPS, an augmented virtuality form of simulation. This was the first nursing study to examine the nature of presence in relation to HF-HPS. Based on the state of knowledge regarding presence in this context and on the complexity of presence as a process of social interaction, a second generation grounded theory approach was used for this inquiry (Charmaz, 2006). Second generation grounded theory approaches adopt the classic methodology first put forth by Glaser and Strauss (1967) and Glaser (1978) including the process of simultaneous data collection, analytic coding, constant comparative analysis, iterative theoretical sampling, and theory construction. Yet, second generation grounded theory methodology has an interpretivist stance aimed at understanding a co-construction of reality that is assumed to be multiple, complex, relative, and situated in context (Charmaz, 2006; Clarke, 2005). Therefore, a second generation grounded theorist may more actively seek the complexity (Clarke, 2005) of phenomena under study in the research process. Second generation grounded theorists also account for an assumption of the interaction of the researcher and the research process on the data and on the theory construction by engaging reflexivity throughout the research process (Charmaz, 2006; Clarke, 2005). For this study, the second generation grounded theory approach most aligned with Charmaz (2006) was utilized. The methodology was used to construct a model of the nature and determinants of presence as defined by nursing student participants in scenario based HF-HPS as well as a theorization of how presence may influence learning outcomes. The core concept of presence from the emergent model derived from this study is delineated in this report.
Ethical Considerations Institutional review boards at each participating simulation center and academic institution gave approval prior to the start of this study. Conduct of this study was guided by the principles of informed consent as well as dynamic and emergent, voluntary participation. Since nursing students and experienced nurse learners were considered captive groups, potential participants were informed that the study was not an academic or a work requirement and assured that participation would not influence their evaluation or standing. In appreciation of the time required for interviews, remuneration was provided. The remuneration was of low monetary value to guard against undue influence.
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Sampling The sample was drawn from two Midwestern simulation centers having academic and hospital affiliations. Consistent with established analytics of grounded theory methodology, an a priori specification of an ultimate sample size was avoided. The criterion for initial inclusion in the study was that participants were late term junior or first term senior level, pre-licensure, traditional baccalaureate nursing students participating in a scenario-based, high fidelity human patient simulation experience as a course requirement. At the outset of the study, a purposive sample of 30 traditional baccalaureate nursing students was recruited. Next a theoretical sample of 32 second degree pre-licensure nursing students was recruited. This sampling provided for a comparison on themes concerning dimensions of life experience, academic development, age, and maturity. As the study progressed, based on other emerging themes and comparative analyses, a sample of 30 experienced registered nurses and 20 academic faculty members and hospital-based nurse educators were invited to participate. To densify the dimensions on categories, two simulation lab directors and one nursing administrator were recruited to participate. The criterion for comparative and theoretical sampling also included that interviewees were either participants or facilitators of the simulations or were administrators having supervisory or budgetary responsibility for the simulation laboratory facilities. The professional, registered nurses participated in a simulation as a job requirement for annual competency training. The theoretical sampling plan was aimed at de-centering the primary participants from an assumed, all knowing position and at providing opportunity for less salient or diverse elements to be revealed. Finally, for stabilization and verification of concepts and linkages in the emergent model and in search of discrepant or disconfirming cases, an iterative sampling return to the primary sample was undertaken. In this sampling, 30 more traditional baccalaureate nursing students were invited to participate. At this point, data saturation and density of concepts were evident.
Data Collection A total of 36 simulations were observed. All simulations were two- hour learning experiences comprised of a preparatory assignment, lab orientation, preplanning session, 60-90 minute simulation scenario and a 20-30 minute debriefing session. The simulations were dynamic, scenario-based simulations concerning declining patient health status (post-surgical hemorrhage, acute myocardial infarction, respiratory failure, septic or cardiogenic shock), and requiring either an urgent intervention or emergency code resuscitation. The design of all simulations included the use of the METI® prehospital model human patient simulator. Observations of the simulations were conducted through a one-way glass window. Two of the simulations were
observed from the side of the room when a one-way window was unavailable. Simulations also were digitally video-recorded for later analysis. A process of descriptive, focused, and selective observation was conducted. A semistructured observation framework was utilized for focused and selective observations to sensitize the observations to relevant elements, but also to allow for emergent elements in the observation. Observation categories included: sensory-perceptual, psychological, actional, processual, and consequential aspects. Participants were informed that they would be observed but were unaware of the observation framework. Jottings were recorded during the simulation encounters and detailed field notes and video transcriptions were completed within 24 hours following the simulation encounters. All participants completed semi-structured group interviews during the debriefing sessions. In-depth, individual interviews were conducted with 94 participants. Individual interviews occurred within 30 minutes to 48 hours following the simulation encounter and lasted 30 to 60 minutes. Timing of the interviews was aimed at the avoidance of significant memory decay among participants. All interviews were digitally audio-recorded and transcribed verbatim. The initial interview prompts were structured around concepts related to presence drawn from the literature to assure elucidation of salient and thematic elements. Semi-structured interviewing also allowed for emergent and non-salient aspects to come to light. Sample prompts included: (a) How would you describe your experience in the simulation? (b) Tell me what you were aware of during the simulation. (c) Describe your interaction during the simulation. Throughout the study, interview prompts were narrowed, broadened, or revised to focus around categories that emerged for theoretical insight (Charmaz, 2006).
Analysis All observations were transcribed and coded in their entirety. A professional transcription company reporting 98-99% reliability transcribed the interviews. All interview transcripts were reread simultaneously with the recordings for initial coding. Classic Glaserian coding (Glaser, 1978) was employed through an iterative process of line by line, open coding, followed by comparative analysis, theoretical sampling, and selective coding. This was followed again by comparative analysis, theoretical sampling, and theoretical coding. As theoretical codes stabilized, the return to sampling again from the primary sample of nursing students provided validation. A preliminary model emerged. The final level of analysis was directed at condensing concepts and raising the level of abstraction in the model. Concepts and linkages from the model were used in the last round of sampling during interviews for stabilization, verification, and validation. Memos were written throughout the analytic process to encourage theoretical sensitivity, to raise the level of
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abstraction, and to generate interconnections between codes and categories (Charmaz, 2006).
Rigor To achieve prolonged engagement, the study was conducted until data saturation was reached which also was a full academic year. The length of the individual interviews was significant in relation to the length of the simulation experience. The interview process was viewed as an active and non-neutral process that would produce a co-constructed (Charmaz, 2006) text. Reflexive journaling was used to acknowledge and minimize a sensitized imposition on the data and analysis (Charmaz, 2006) with particular concern for preconceptions around the concept of presence from the literature and from other contexts. The use of triangulation of observation and interview methods aimed to avoid decontextualized data collection (Charmaz, 2006). Triangulation through sampling from different institutions and comparison between sampling groups further enhanced confirmability. Member checks during validation interviews also enhanced confirmability. A significant audit trail of 130 audio files and 36 video files provided dependability of the study data. The rich yield of narrative transcription text provided the evidentiary adequacy of this study and supported the use of rich quotation passages from participants that reflected the essence of the nature of presence in HF-HPS reported in this study. The limitations and reductions of transcription and coding as well as the potential for researcher interactions on observation and interview data may have influenced the results of this study, despite all of the measures for protection undertaken against these threats. It is also possible that a broader range of participants and simulation contexts could have yielded additional or differing findings.
Findings The final sample consisted of 145 participants. The age range of students was between 20 and 36 years. The range of age among registered nurses, faculty members, and administrators was between 23 and 60 years. Gender and ethnic patterns in the sample were similar to the national percentages among the registered nurse populations reported by the most recent United States Department of Health and Human Services Survey of the Registered Nurse Population (2010).
Centering Presence Students and professional nurse participants described and were also observed having multidimensional and dynamic states of presence as they interacted in simulation scenarios. These states were most characterized by a centricity. Centricity refers to the locus of the state of being in interaction based on the salience of perception of stimuli from the simulation environment in relation to the natural environment. Two primary
states of presence centricity were evident: endocentric presence and exocentric presence. Participants seemed to center their presence primarily inside the simulation scenario (endocentricity) interacting fully in the simulation environment or outside the scenario interacting more with the natural or proximal environment (exocentricity). Presence was a fluid and dynamic process that occurred throughout the simulation experience. Presence centricity conditioned meaning and mediated interaction in the situation influencing both experience and action. Endocentric Presence. Many nursing students became drawn into the situation in such a way that the simulation situation overtook their focus and attention. The natural environment faded in the background. Their senses were engaged by the stimuli and interactions of the simulation scenario. They became cognitively involved and enacted a care-giving role in an embedded psychological state of being, as if involved in a real patient care situation. As one faculty member participant observed, It seems like it is all about being drawn into the situation. The situation overtakes them. Then it is like they are there – in the real. It is like they are involved and immersed into it. Their focus is really [emphasis] on the patient and on what’s happening with them, and what they should do about it.
Another faculty member participant stated, “It is like they become tunnel-visioned on the patient and everything else around them is just gone.” Thus, endocentric presence in HF-HPS is conceived as a dominant perception of being and enacting the self as if in a role in the real patient care situation represented by the simulation. Endocentric presence is indicated by a state of immersion (sensory-perceptual envelopment) and involvement (focus/attention/action) in the simulation situation similar to Witmer and Singer’s (1998) description of presence in computer simulations. One student’s comment reflects the endocentric state of being. Note in the next passage the dominance of the patient situation over the proximal environment and the perception of being there in a real patient care circumstance. Well, the patient was my main concern. At first it was pain; it was hurting her and that was my concern. Then the second thing, it was the hemorrhage and we had to try to keep the patient calm while we had to deal with the blood transfusion. I felt like a nurse. It was like you see one thing and the next in the simulation and you focus on that and do something to fix it. You kind of forget the fake picture. Do you know what I mean? You get involved in the situation like it is real. You don’t even notice other things around you while you are involved in it, you know?
Exocentric Presence. A second state of presence also emerged where students were interacting with the simulation; yet, they
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Dunnington remained acutely aware of the natural surroundings as if they were being watched and made to perform. Their focus and attention remained more on the outside of the scenario situation. Their interaction displayed a degree of self consciousness, dismissiveness, and disconnection. They stood back and watched almost as if uncomfortably waiting to be forced into becoming involved in the situation. One faculty member participant described this state of being in the following way. They don’t feel that it is real because they are being forced into talking to a dummy. You can really see if they are not engaged in the simulation. They start having their own personal conversations socially outside of the situation. They are like outside the scenario. They are not immersed and not present in it. In fact they act even a little bored. Or they are dismissive when they do something wrong and they say, “Oh well, it isn’t real anyway.” They go through it like it is just pretend [and has no consequence.]
Based on emergent patterns in this study, exocentric presence is conceived as a dominant state of being in and interacting with the natural environment where the meaning of the simulation environment is perceived strongly as artificial. The participant enacts the role from an outsider perspective disconnected from the simulated patient-care situation. Their interactions and actions with the simulation are thereby constrained by the meaning of the artificial environment and the dominance of perceived stimuli of the natural environment. Students similarly characterized their experience in HF-HPS as a state of being either inside the simulation situation or on the outside of the situation. The student here recounted a more exocentric state of being in the simulation. Notice in this narration that the student was highly aware of the artificiality of the simulation activity and was concerned with the observers and facilitators in the proximal, natural environment. The dominance of the natural environment seemed to mediate on the student’s perception, actions, and experience. I felt so awkward. I don’t know if it’s just because of in my mind, I know it’s fake. I guess I just felt like I was outside like watching everybody inside paying attention and attending to it. It felt unnatural almost. I know I was busy with stuff, like just doing the tasks, like I was going through the motions, like it would be scripted. I wasn’t really worried about the patient or that I am going to hurt anything. I was just thinking about the people in the booth and the teacher watching and it just doesn’t make it seem real to me at all. It is just a weird psychological thing, you know?
Shifting Presence Bicentric Presence. While participants did describe and were observed in discrete states of endocentric and exocentric presence interactions, the experience of the majority of students in this study can be interpreted as being in a more bicentric state of presence. During bicentric presence interactions, students
were predominantly aware and interacted in one environment, while still maintaining awareness and interaction with the other. Bicentric presence in HF-HPS is conceptualized here as a state of being in which both the simulation and the natural environment are perceived and experienced dynamically at varying degrees of intensity. In this state of being, the degree of perception and action were generally centered with greater intensity in one environment or the other. There was a degree of overtake by the simulation environment; yet, the participant remained aware of the primary environment to some degree. This is consistent with the simultaneous experience of both a natural and a virtual environment that has been described of presence in other types of virtual simulation environments (Ijsselsteijn, 2002). One student described the experience of bicentricity in HF-HPS in this way. “Yea, the simulation was real and not real enough at the same time. I felt right in-between. Yes, right in-between something real and not real at the same time. Like one foot in and one foot out.” Another student also described a bicentric state of being in simulation where starting from an endocentric position, her awareness of the natural environment, exocentricity, became salient. I started out very focused on the situation. I was working with the primary nurse to figure out how we should get things accomplished. But then, sometimes, I feel, just like laughing like, this isn’t real and I feel like I pulled right of the situation.
Another student’s reflection also illustrates the dynamic of bicentric presence. She described how the stimuli from the patient condition in the simulation overtook her from a more exocentric state to a more endocentric state of being. It was kind of an odd experience. Like at first you feel silly taking it seriously because he isn’t real. You feel at first like you are just yourself pretending. But at the same time, once he started to decline and he went into V-fib, I kind of had this sense of urgency to fix it. I got nervous and the adrenalin was pumping. Even though I knew he wasn’t a real patient, it got so nerve wracking because you kind of put yourself in the real scenario. It was this sense of urgency that came over me that kind of surprised me. It kind of put me there like in a real life situation. I had the sense of fear that the patient would be dying – that sense of fear that I would have if it were real.
Breaks in Presence. As described by participants, bicentric presence is a dynamic state in which the student moves between the proximal and the simulation environments. At times this was a gradual shift from one environment to the other where students were drawn in by the situation from an exocentric state of being on the outside of the situation to an endocentric state of being on the inside of a seemingly realistic patient situation represented in the simulation. Yet, in the example of the student that described a sense of being “pulled out of the situation” the perceptual and attentional shifting (Ijsselsteijn, 2002) can also be more fully in or out of the simulation to more discrete states of endocentricity
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or exoentricity. This abrupt shift in presence is aligned with the concept of breaks in presence originally described by Slater and Steed (2000). This occurs when participants in simulation stop attending to the stimuli of the virtual environment and attend more to the stimuli from the natural environment. Breaks in presence seemed at times facilitative and at other times seemed counterproductive to maintaining or restoring an endocentric state of being relative to the HF-HPS environment among study participants. For example, at times students participating in HF-HPS are called upon to enact the role of the nurse requiring skills for which they may or may not have full knowledge or competency to perform. It is in this case that breaks in presence most often occurred. These students chose to draw on the natural environment by asking the instructor or the facilitator for assistance. At other times, instructors broke presence by interrupting the scenario from the outside to draw students’ attention to a cue in the simulation, to assist in task performance, or to prompt clinical reasoning regarding the patient situation. The examples that follow illustrate that a student-initiated break in presence could be facilitative; whereas, an instructor-initiated break in presence seemed counterproductive. This student described a situation in which the break in presence facilitated endocentric presence in the simulation. Sometimes we stopped to ask the teacher a question. I remember that I kind of stopped and turned to her and asked the question because she was sitting right out there, but not really. But then I went right back into the situation doing something with the patient and I was really into it again. Sometimes you just need to get a thing that you don’t know answered so you can go on in the situation.
Another student also explained the facilitative nature of a student initiated break in presence. Well sometimes it was necessary to ask a question because if we didn’t, we would have been stumbling or just frozen. It is like you just put it on pause to ask a question and then un-pause and start up again right from where you were.
However, a break in presence also can be counterproductive. This student described a state of moving to a completely exocentric state of being in the simulation when the instructor initiated a teaching moment in the simulation. Her words conveyed the sense that part of the learning experience was lost by this shift. When she jumped in and started doing things in the simulation and talking about things in the simulation, it was pretty much over for me. I would say that it just broke me out of the simulation and now it was just a lab situation again and it just turned into a teaching session, again. That was OK, but if the point was for us to go through a realistic patient care situation, it was all over after that.
Nature of Presence in HF-HPS Three presence states were evident through the observations and the interviews of the participants. Dimensions of these states also clearly emerged from these data. Endocentric presence is characterized by a sense of “being there” or “putting oneself” in the framing of a real patient care situation. Once there, those that were endocentrically present in HF-HPS were observed to have high levels of immersion, focus, and attention and to be less influenced by distractions in the surrounding natural environment. This seemed to foster high cue sensitivity and a sense of agency in the patient care situation. Endocentric presence also was characterized by emotional responses related to the care situation. These included a sense of urgency, nervousness, fear, or compassion. Participants experiencing an endocentric presence perceived a connection to the patient situation and felt a sense of responsibility and accountability for the patient status in the simulation as can be seen in the responses of participants. In contrast, participants that experienced a more exocentric presence framed themselves outside the patient care situation and described resisting or feeling forced into being in the situation. Their focus and attention appeared to be more on others in the natural environment and on the self as a performer in the situation. These participants exhibited reduced cue sensitivity and higher levels of distractibility. They perceived the situation as artificial and inconsequential. This fostered low perceived levels of agency, emotion, and accountability. Bicentric presence was observed to be the most common presence interaction among participants in HF-HPS. This state of being was characterized by the participant’s perception of and interaction with both the natural and the simulation environment at some level of salience of one over the other. Bicentricity was further characterized by a salience of presence in which either endocentricity or exocentricity was dominant and as Ijsselsteijn (2002) has described in other virtual contexts, where participants were always aware of the other environment often experiencing shifting attention (Ijsselsteijn, 2002) between the proximal and the simulation environment.
Discussion Presence has received wide attention across disciplines for its central importance to the participant’s experience with other forms of virtual reality simulation and the likely impact on task performance or other outcomes. The nature of presence in HF-HPS described in this study is consistent with and supports evolving conceptualizations of presence in related virtual contexts. Presence among participants in this study was multidimensional and complex. The dimensions of presence included immersion and engagement as has been found in other virtual simulation environments (Wither & Singer, 1998; Slater & Wilbur, 1997). As others have also reported in virtual simulations (Ijsselsteijn, 2002; Herrera, Jordon & Vera, 2005; Slater & Steed, 2000), presence in
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Dunnington HF-HPS was characterized in this study by perception of reality, suspension of disbelief, cognition, action, agency, and psychological responses to the simulated patient-care situation. Based on the results of this study, the nature of presence in the context of interaction mediated by HF-HPS is conceptualized as a sensory-perceptual, cognitive, psychological and actional engagement in an experience where the stimuli of the simulation environment immerses the participant in artificial representation of a natural human phenomenon, and where the individual perceives the experience at a level of realism and salience as an agentic, caring self. Presence is further conceptualized in the context of HF-HPS as a dynamic state of being in which individuals experience centricity between the simulation environment and the natural surrounding environment, and in which participants perceive the stimuli from one environment to be salient over the other. The centricity of presence has primary domains of either exocentricity or endocentricity relative to the simulation environment. As a dynamic state of being, participants also may be drawn inside or outside of the simulation situation (breaks in presence) or may experience both the simulation and the natural environment simultaneously (bicentricity) at varying degrees of salience. The concept of presence centricity used here is somewhat related to similar terms used in the context of other virtual environments. Slater and Wilbur (1997) and Salzman, Dede, and Loftin (1999) refer to the terms egocentric and exocentric to define frames of reference in the graphic design of virtual display environments. In their work, these terms refer to the human - computer interface that provides the view that places the user’s perspective on the inside or the outside of virtual environment. However, presence centricity conceptualized in the context of HF-HPS is differentiated here. The concepts of endocentrism and exocentrism in relation HF-HPS, a mixed reality form, refer to the perceived salience of the simulation environment over the natural environment as they co-mingle. The virtual aspect of HF-HPS co-mingles human and nonhuman elements among the stimuli and cues of the scenario enactment. Consequently, participants become immersed, engage, and interact on the inside or the outside of the simulation scenario environment by their own volition. Earlier work on presence in other disciplines has conceived presence existing in exclusive modes between the natural and virtual environments. In this study, the concept of centricity of presence was shown instead to be a dynamic state of being in which the stimuli of either the natural environment or the simulation environment is salient (endocentricity versus exocentricity) but where both environments may be experienced simultaneously (bicentricity). This conceptualization supports Ijsselsteijn’s (2002) findings of presence intensity. The findings of this study are also consistent with the concept of breaks in presence that have been identified in virtual simulation environments. Breaks in presence are the dynamic states of being present in simulation where the participant abruptly stops responding to the virtual stimuli and instead immerses in the stimuli of the natural proximal environment
(Slater & Steed, 2000). Breaks in presence also were noted in this study and were typically invoked by distraction from the natural, proximal environment or by the interaction of the facilitator of the simulation. The finding of breaks in presence further supports the conceptualization of presence in HF-HPS as a dynamic state of being. HF-HPS, an augmented virtuality (Milgram & Kishino, 1994), represents a different socio-technical milieu than other virtual forms of simulation. By nature, this hybrid form of simulation mixes the natural environment (human interactions in the patient care situation) and the virtual environment (artificial mannequin patient, computer displays, and scenario enactment) involving a participant simultaneously being and interacting in both the natural and the virtual environments. Natural human interactions between participants are integral to the enactment of the simulation. Facilitators are required for the implementation of the scenario states and stimuli. Therefore, the proximal and the simulation environments co-exist and may mediate on the participant experience in various ways. The increasing use of technology in nursing education has led to questions regarding the potential for presence in the context of virtual reality and HF-HPS (Condon, 2013). Results of this study suggest that states of presence do exist among participants in scenario-based high fidelity simulation. This study also demonstrated that an immersive, endocentric presence is clearly inducible with scenario-based high fidelity human patient simulation. The nature of endocentric presence experienced by participants in this study displayed attributes both similar and different from presence as it has been described in the natural context of nurse-patient interactions. The findings of this study then, add information to the nursing literature on presence as specified with the attributes of engagement, attentiveness, intentionality, immersion, therapeutic agency, connection, and the sense of being with articulated by Parse (1998), Paterson and Zderad, (1976), Watson (2007), and Kostovich (2012) who wrote that nursing presence was a “multidimensional unified whole fluidly existing in the cognitive, affective, behavioral, and spiritual…domains” (p. 169). The endocentric state of presence in the context of the simulated nurse-patient interactions in HF-HPS displayed similar attributes to presence in natural nurse-patient interactions. Participants in this state of being described the experience of being immersed in a perceived real situation with attributes of attention, engagement, involvement, cognition, therapeutic agency, and affective responses. Presence in the context of HF-HPS was experienced as a mediated state of being in interaction. Participants seemed to engage more with a perceived situation rather than being engaged in interaction in the sense of being with another person. They seemed to perceive the patient as a rather disembodied other, yet projecting themselves forward into an imagined nurse- patient interaction. While nursing students in this study experienced affective responses, presencing more with a perceived situation lacked the interpersonal connection and mutual experience of intimacy, sensitivity, or commitment of
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the affective and spiritual domains that have so often been attributed to presence in the therapeutic-caring relationship of the natural nurse-patient interaction. Despite this difference, an endocentric presence in the technology- mediated situation of HF-HPS seemed to offer as Kiran (2012) has described an experience of the actuality of the simulated-patient situation and as a potentiality of the real patient situation. In this way, as Condon (2013) has noted, a technology-mediated presence as in the context of HF-HPS is differentiated from presence in natural nursepatient interactions.
Conclusion Presence is a means by which participants experience reality in social interactions. The close connection with reality that presence affords in simulation makes presence a potentially important consideration for research concerning clinical simulation. This study makes a foundational contribution to nursing regarding an understanding of the nature of presence related to the context of HF-HPS. Theorizing from the extant state of knowledge on presence (Kostovich, 2012; Parse, 1998; Paterson & Zderad, 1996; Watson, 2007), and from the larger presence model generated from this study, pedagogic support of endocentric presence in HF-HFPS may lead to more educative learning outcomes that may transfer to the real clinical situation. Further research to examine the relationship between presence and learning outcomes also may support development of the educational science related to clinical simulation in healthcare and may further support the development of healthcare professionals. Scenario-based high-fidelity human patient simulation is a technology and a technique that is increasingly authentic having the potential to amplify and to reveal a variety of natural clinical patient care situations. Simulation may invoke the imaginative capacities of participants allowing them to experience a centricity of presence as if in the real clinical situation. It is the connection to the experience of reality that presence affords in simulation that bears its significance. Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the authorship and/or publication of this article.
Funding The authors received no financial support for the authorship and /or publication of this article.
References Charmaz, K. (2006). Constructing grounded theory: A practical guide through qualitative analysis. Los Angeles: Sage. Clarke, A.E. (2005). Situational analysis: Grounded theory after the postmodern turn. Thousand Oaks: Sage. Condon, B. B. (2013). The present state of presence in technology. Nursing Science Quarterly, 26(1), 24-28.
Dieckmann, P., Manser, T., & Wehner, T. (2003, October). Presence and high fidelity patient simulators in anaesthesiology: Influences derived from interviews and questionnaires. Proceedings of PRESENCE 2003 the 6th Annual International Workshop on Presence. Aalborg Denmark. Retrieved from http://www.temple.edu/prev-conferences/proceedings/2003/ Dieckmann,Manser,Wehner.pdf Glaser, B. G. (1978). Theoretical sensitivity. San Francisco: Sociology Press. Glaser, B., & Strauss, A. (1967). The discovery of grounded theory: Strategies for qualitative research. New Brunswick: Aldine Transaction. Goffman, E. (1959). The presentation of self in everyday life. Garden City, NY: Anchor. Herrera, G., Jordon, R., & Vera, L. (2005, September). Agency and presence: a common dependence on subjectivity? Proceedings of PRESENCE 2005: The 8th Annual International Workshop on Presence. London. Retrieved from www.temple.edu/ispr/ prev-conferences/proceedings/2005/Herrera,Jordan,Vera.pdf Ijsselsteijn, W. (2002). Elements of a multi-level theory of presence: Phenomenology, mental processing and neural correlates. Proceedings of PRESENCE 2002: The 5th Annual International Workshop on Presence. Retrieved from http://www.temple. edu/ispr/prev-conferences/proceedings/2002/Ijsselsteijn.pdf Kiran, A.H. (2012). Technological presence: Actuality and potentiality in subject constitution. Human Studies, 25, 77-93. Kostovich, C.T. (2012). Development and psychometric assessment of the presence of nursing scale. Nursing Science Quarterly, 25(2), 167-175. Milgram, P., & Kishino, F. (1994). A taxonomy of mixed reality visual displays. IEICE: Transactions on Information Systems, 77, 1321-1329. Minsky, M. (1980). Telepresence. Omni, 2, 45-51. Parse, R. R. (1998). The human becoming school of thought. Thousand Oaks, CA: Sage Publications. Paterson, J. G., & Zderad, L. T. (1976). Humanistic Nursing. NY: John Wiley & Sons. Salzman, M. C., Dede, C, & Loftin, R.B. (1999). VR’s Frames of reference: A visualization technique for mastering abstract multidimensional information. Proceedings of the SIGCHI Conference on Human Factors in Computing Systems: The CHI is the Limit, pp. 489-495. NewYork: ACM Press Slater, M., & Steed, A. (2000). A virtual presence counter. Presence: Teleoperators and Virtual Environments, 9(5), 413-434. Slater, M., & Wilbur, S. (1997). A framework for immersive virtual environments (FIVE): Speculations on the role of presence in virtual environments. Presence, Teleoperators and Virtual Environments, 6(6), 603-616. U.S. Department of Health and Human Services (2010). The Registered Nurse Population. Retrieved from bhpr.hrsa.gov/ healthworkforce/rnsurveys/rnsurveyfinal.pdf Watson, J. (2007). Nursing: Human science and human care – A theory of nursing. Boston: NLN Press, Jones and Bartlett. Witmer, B. G., & Singer, M. J. (1998). Measuring presence in virtual environments: A presence questionnaire. Presence, Teleoperators and Virtual Environments. 7, 225-240. Zhao, S. (2003). “Being there” and the role of presence technology. In G. Riva, F. Davide & W. A. Ijsselsteijn (Eds.), Being there: Concepts, effects and measurements of user presence in synthetic environments (pp 137-145). Amsterdam: IOS Press.
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