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research-article2014

NSQXXX10.1177/0894318414558605Nursing Science QuarterlyDunnington

Article

The Centricity of Presence in ScenarioBased High Fidelity Human Patient Simulation: A Model

Nursing Science Quarterly 2015, Vol. 28(1) 64­–73 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0894318414558605 nsq.sagepub.com

Renee M. Dunnington, RN; PhD1

Abstract Enhancing immersive presence has been shown to have influence on learning outcomes in virtual types of simulation. Scenario-based human patient simulation, a mixed reality form, may pose unique challenges for inducing the centricity of presence among participants in simulation. A model for enhancing the centricity of presence in scenario-based human patient simulation is presented here. The model represents a theoretical linkage among the interaction of pedagogical, individual, and group factors that influence the centricity of presence among participants in simulation. Presence may have an important influence on the learning experiences and learning outcomes in scenario-based high fidelity human patient simulation. This report is a follow-up to an article published in 2014 by the author where connections were made to the theoretical basis of presence as articulated by nurse scholars. Keywords education science, grounded theory, presence, simulation, technology A primary goal of scenario-based high fidelity-human patient simulation (HF-HPS) in nursing education is to provide clinical experience through the enactment of a realistic and dynamic care situation. One of the educational challenges of this type of simulation is to induce a sense of “being there” (Minsky, 1980) in a realistic clinical context. Fundamental to this goal is presence in the simulation where the participant perceives being in the real patient care situation and as a result, experiences a sense of responsibility and accountability for influencing the patient outcome. The idea of presence as significant to patient care articulated by nurse scholars and theorists was discussed in the precursor to this article (Dunnington, 2014). Centricity of presence refers to a state of being whereby the participant experiences sensory, perceptual, and actional dominance with regard to a field or environment of interaction (Dunnington, 2014). More specifically, an endocentric presence is the dominant perception of being and interacting in a real patient care situation represented by the simulation (Dunnington, 2014). Scenario-based HF-HPS may pose particular challenges to inducing the centricity of presence in the simulation situation. With completely virtual computer simulations, the natural environment is more easily excluded from the awareness of the participants making immersive presence more readily inducible by greater sensory overtake and fulfillment. Yet, HF-HPS, as a mixed reality form, encompasses a co-mingling with the natural environment and face-to-face role-play interaction among participants.

These interactions may compete with the virtual context of the simulation scenario enactment potentially making endocentric presence among participants more complex or difficult to achieve. Presence has been shown to be an influential factor on learning outcomes in virtual computer simulations (Ragan, Sowndararajan, Kopper, & Bowman, 2010). This makes presence an important consideration in relation to HF-HPS. Individual immersive tendencies (Witmer & Singer, 1998; Banos et al. 2004), cognitive factors (Sas & O’Hare, 2003; Slater & Usoh, 1993), and personality traits (Wallach, Safir, & Samana, 2010) have all been shown to influence presence in virtual reality simulations. A high concentration of research exists concerning technology-specific media forms that influence presence (Kalawsky, 2000). Yet, limited work concerning variables that may influence presence related to clinical simulation is evident (Dieckmann, Manser, & Wehner, 2003). A grounded theory study was conducted to examine the nature of presence in HF-HPS and to examine factors that may influence presence in simulation. The first report from that study (Dunnington, 2014) presented the methodology and defined the construct of presence centricity that emerged. This is the second report from that study. Presented in this report is a conceptual model of presence centricity in HF-HPS and the pedagogical, individual, and group factors 1

Associate Professor, Capital University

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Figure 1.  Centricity of Presence in HF-HPS

that emerged as conditioning categories that influenced presence and the learning experience. The model was generated from the study data first reported in Dunnington (2014). It is presented in this report with additional findings from that study supporting the factors and linkages in the model. The model is generated as a framework to help build the educational science for clinical simulation in nursing and to help guide future research that would be aimed at maximizing presence and learning outcomes with scenario based HF-HPS.

Centricity of Presence in HF-HPS Model The centricity of presence in HF-HPS model is presented in Figure 1. Presence in scenario-based HF-HPS is shown to be a dynamic state of being between the primary domains of endocentricity and exocentricity relative to the simulation environment. These concepts refer to the locus or the centricity of participants’ state of being having sensory, perceptual, and actional dominance from the stimulation either on the inside (endocentricity) or the outside (exocentricity) of the situation represented by the simulation (Dunnington, 2014). The middle rectangle in Figure 1 represents the stimuli of the natural, proximal environment. The stimulus from the simulation environment is embedded within a natural environment and is represented in the model by the shaded expanding triangle. Participants are shown in the model by the diamonds at various positions on a continuum within the expanding triangle representing the salience of the stimuli of the simulation environment and the resultant degree of engagement and

involvement in the simulation. Participants depicted at the point end of the triangle are more exocentrically present having a state of being and interaction more dominantly in the natural environment. Participants shown at the wide end of the expanding triangle are more endocentrically present having a state of being and interaction more dominantly in the simulation environment. The boundary between the proximal and simulation environment represents a permeable boundary where the stimuli from both environments co-mingle. This co-mingling is a primary basis for the dynamic nature of presence in HF-HPS where participants may shift their state of being present, attending and interacting more inside or outside of the simulation situation (Dunnington, 2014). This core concept of the centricity of presence and the dynamic nature of the salience of presence between endocentricity and exocentricity is more fully described in Dunnington (2014). Multiple factors influenced presence among participants reported in Dunnington (2014); these factors are fully reported here in this second report from that study. The factors are shown in the model as determinants of presence. The factors are clustered into the broad categories of pedagogical factors, individual factors of learners, and group factors among participants in the simulation. The bi-directional arrow indicates the interaction among these factors that may influence presence in HF-HPS. Furthermore, the experience of presence in the simulation may bear on the learning experience in either educative or mis-educative (Dewey, 1938/1986) ways. The model shows a linkage between a more endocentric state of presence among participants and more educative experiences or more positive learning outcomes in scenario-based HF-HPS.

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Pedagogical Factors Broadly, pedagogical factors are those factors that relate to the instructional-learning strategy, design, method, style, and activities. Pedagogical factors are widely accepted as contributing to learning outcomes. Simulation design, implementation, and group factors emerged as categories in the model that either induced or inhibited an endocentric presence in this study. Simulation design factors.  Simulation design refers to features such as objectives, fidelity, problem-solving, student support, and reflective thinking/debriefing (Jeffries & Rogers, 2012). The purpose and objectives of the simulation seemed to influence presence centricity among participants. Additionally, features of the scenario and of fidelity also had bearing on the salience of the simulation environment experienced among participants. Purpose or objectives.  The purpose or objectives of a learning activity function to guide the design of the activity, provide the framework for evaluating learning, and guide the learner through the process of achieving the learning goal (Morrison et al., 2013; Jeffries, 2012; Bastable, 2013). Learning objectives for simulations in nursing education tend to most directly address either the goals of psychomotor skill attainment or higher order critical thinking, problem solving, and clinical judgment goals around clinical problems. When the purpose of simulation is oriented toward the goal of achieving skill or demonstrating task competency, an exocentric presence may be expected since the simulation is typically instructor-driven. However, with dynamic, scenario-based HF-HPSs that are intended for instructional or for formative learning goals, an endocentric presence is desired to enable problem-solving and clinical judgment as if in a real situation. The use of HF-HPS as an evaluation method and the participant’s perception of being evaluated even when HF-HPS was used as an instructional method, negatively influenced the centricity of presence in the simulation among participants (Dunnington, 2014) When participants were aware that the purpose of the simulation was for competency evaluation, they experienced higher anxiety, concern over being watched, and suspicion of being set up or tricked leading to more exocentricity of presence. Similarly, participants in instructionally-based simulations who perceived that they were being evaluated, although they were not, still experienced anxiety, concern with being watched, and a more exocentric presence as represented in this participant’s words. It is very stressful having your instructor in there and watching you so closely because you know, even if they say this is just a learning experience; they will remember what you did wrong. So that is in your mind when you are going through it.

Scenario design. Scenario design is a scripted template for enactment through a clinical problem and a constructed

context of factors related to the fidelity to the patient care situation, including the environment, equipment, medication/fluids, diagnostics, documentation forms, roles, (Childs, Sepples, & Chambers, 2007) resources, and processes. Dynamic scenario-based HF-HPS design typically includes a patient situation that runs through a progression of physiologic changes in states and responses to nursing interventions aimed at solving the patient problem. The simulations reported in the Dunnington (2014) study included four different scenarios including the problems of post-surgical hemorrhage, acute myocardial infarction, cardiogenic shock, and sepsis. All scenarios included a declining patient status requiring nursing interventions to stabilize the patient’s condition. There were no specific differences noted in presence based on the type of patient problem represented in the simulation. However, the change in physiologic states and the cues indicating those changes seemed to be a strong factor invoking the salience of the simulation environment and a more endocentric presence among participants. Participants often started off standing on the periphery of the situation in a more disconnected and observational mode. Then as the changes became evident, participants were drawn closer. The simulation environment became more dominant through a sensory-perceptual overtake induced by the cues in the simulation design. This student described how the urgency created by changes in states in the scenario overtook her senses to a more endocentric presence. Things were happening and changing so fast and it was so realistic! Her blood pressure was decreasing, her pulse was getting tacky; she was bleeding. I was so focused on all that, that I didn’t feel like anybody was even in the room with us.

Fidelity factors.  Fidelity in simulation is generally considered to be the level of realism represented in the simulation. An aim of simulation design is to develop the artificially- constructed situation as close to the real situation as possible (Jeffries & Rogers, 2012). In HF-HPS, fidelity factors typically include scripting the patient history and progression of the clinical problem, programming, equipping, and making up the patient simulator, scripting the verbal responses and cues of the simulator and facilitator roles, and designing and equipping the environment/setting with supplies, resources, and processes. Fidelity factors influenced the centricity of presence among participants. All student participants mentioned realism, or the lack of realism, as a facilitative or an inhibitory factor in their experience of presence in the simulation. One student said, “We got to actually push meds into the CVC. We got to do all those processes and then we really hung the blood. I really felt like the nurse; it really gets you into it [like it is real].” Yet, other students reported on the inhibitory effects of low fidelity factors when either processes varied, equipment was unavailable, or when the patient did not seem real. “Everything was wrong. They didn’t have gloves. We had

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Dunnington different paperwork. The meds were not in the right vials. It was so confusing…That just breaks your concentration right out of the situation.” Implementation Factors.  Simulation environments provide a “continuous stream of stimuli and experience” (Witmer and Singer, 1998, p. 277) that are intended to envelope participants by providing sensory-perceptual overtake and psychological fulfillment to induce an immersive presence. The stream of stimuli generated from the HF-HPS environment is produced through data, cues, and prompts given from the mannequin operator, educator/facilitator, and other cueing mechanisms such as monitor data output, patient records, patient reports, and scripted role enactments. The stream of stimuli generates the scenario progression and moves the participants through the problem-solving process in the clinical situation represented in the scenario. The stream of stimuli including the pace and number of foci were found to be a strong influence on whether the participants achieved endocentricity. Pace of Stimuli.  The pace of stimuli in HF-HPS is determined both by the design of the scenario progression and by the judgment of the actors, operators, and/or facilitators during implementation. The pace of stimuli in the scenario is on one level apportioned to the timing of the sequence of physiologic/psychological state changes established for the clinical situation designed for a dynamic scenario. Within the physiologic and psychological states designed in the sequence of the scenario are also holding patterns that give participants time for assessment, cue recognition, clinical reasoning/ judgment, and clinical interventions. Throughout both static and dynamic states, a stream of stimuli is delivered to participants through data, cues, and prompts. During scenario implementation, pacing can also be altered as a result of, or in response to, the interactions and interventions of the participants. Pace is further affected by the acceleration of real time in simulation to enact a real patient situation in an allotted laboratory time frame. Pacing the stream of stimuli either too fast or too slow in a dynamic, scenario-based simulation altered immersion and consequently the centricity of presence in the participants in the study (Dunnington, 2014). When the pace was slow, there was a lack of sensory-perceptual fulfillment. Attention and focus on the simulation diminished and a shift of attention to the natural environment, an exocentric presence, occurred. When the stream of stimuli was paced too fast, participants become overwhelmed and over-stimulated. Focus of participants became diffuse. Participants at times completely missed cues or prompts or even become “frozen” in their state of being in the simulation. This too led to attentional shifts to outside the simulation situation or a bicentricity of presence as participants sought assistance or relief from cognitive overload.

Nearly all faculty facilitators or simulator operators described the challenge of pacing the data, cues, and prompts in the simulation. One instructor facilitator/operator put it this way: If you move very quickly in the scenario, they get frazzled. They start falling apart when that happens. If it is too slow, then they come out of it and they start talking about other things in their lives and they are not focused on the simulation.

Similar patterns of immersive presence were expressed by nursing student participants. One student described this pattern in this way. “Everything is thrown at you all at once, so your focus just scatters.” When the pace of the stimuli in the stimulation was too slow another student stated, “When everything was moving so slow, it was distracting. I was thinking that we just needed to get things done… and it didn’t seem like a real situation anymore.” Scenario Foci.  The focus points in a scenario-based simulation are a part of both simulation design and implementation. Foci include not only the primary patient problem that the participants must solve and treat, but also include any other learning objectives, learning activities, physiological states, psychomotor skills, and psycho-social aspects that accompany the clinical situation and require the participant’s attention in the simulation. Foci are important elements in design consideration since they contribute to the realism and complexity of the simulation and to the distraction away from the focus on the primary patient problem or learning objective. As such, foci become another source of stimuli for the participants in the implementation of the simulation. Jeffries and Rogers (2012) have suggested that the complexity of a simulation design should reflect the purpose of the learning experience, the learners’ ability, and should present a challenging, problem-solving situation. But complexity of the simulation may also reduce the effectiveness of the learning experience or may overload the learner (Jeffries & Rogers, 2012). The challenge here is in trying to achieve a match between the cognitive, psychomotor, and affective demand of the simulation with skill level of the learners. Students and professional nurse participants spoke of the difficulty focusing on the primary problem when they became overwhelmed with stimuli related to the number of foci in simulation. One student stated, “The patient just kept complaining and throwing up and throwing up. It was so distracting, I even was annoyed by it…we couldn’t even get to treating her blood loss because we kept having to go back with the emesis basin so many times.” Similarly a professional nurse participant shared how the number of foci influenced her learning experience negatively causing her to feel suspicious of the situation. Sometimes when they are making so much stuff happen and giving you so many clues, you just get the feeling like they are

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saying things to throw you off. So you don’t know what to take seriously in the simulation. Then you just read into it cause its half pretend.

Cognitive load theory (Baddeley, 1986, 1999) posits that cognitive overload occurs when the cognitive capacity is exceeded in a learning activity where learners become overwhelmed by the number of information elements and interactions that need to be processed ultimately influencing meaningful learning (Paas, Renkl, & Sweller, 2004). A high potential of cognitive overload from the learning experience by HF-HPS was evidenced in both the observations and interviews from the study (Dunnington, 2014). Such cognitive overload from a fast stream of stimuli or excessive number of foci altered presence and had the potential for a negative impact on the learning experience and learning outcomes among participants. Instructional process.  The instructional process refers here to the facilitation process and the nature of student-teacher collaboration during the simulation. The instructional method was found to be a pedagogical factor that is a determinant of presence in HF-HPS (Dunnington, 2014). The relationship with faculty or the nature and style of facilitation were also found to stimulate either a more endocentric or exocentric state of presence (Dunnington, 2014). Positive faculty-student relationships seemed to allay perceptions and fears of being evaluated; whereas, negative faculty-student relationships seemed to promote fear and anxiety interfering with engagement and attainment of endocentric presence. Both teachers and students described circumstances of impact from the nature of the faculty-student relationship. An instructor that typically took the role of the mannequin operator described some of her observations in this passage. When you have a very authoritarian teacher, I think that makes students extremely nervous. I have seen students literally shaking and with terror in their faces…This is very counterproductive. They cannot engage in the scenario and learn that way. I have also seen instructors that …play a supportive role when they facilitate, then the students respond better. They are not paralyzed by the anxiety. Then they can focus and engage.

The style of facilitation during the simulation was another instructional process factor that had bearing on presence. Jeffries and Rogers (2012) referred to this as the collaboration between faculty and student during the simulation. They suggested that collaboration with mutual respect, comfortable exchange of information, high expectations, and constructive feedback would foster positive learning in simulation. Yet there is controversy in the discipline regarding what is considered best practice for the instructional process during implementation of a HF-HPS. The more often quoted recommendation is that teacher/facilitators remain

more as outside observers to promote independent problemsolving among participants. Data from the study (Dunnington, 2014) suggested that a supportive and embedded instructional process would promote an endocentric presence and a more positive learning experience in this situation when the purpose of the simulation is educational rather than evaluative. The data also suggested that the use of the outside observer and detached mode of facilitation led to the perception of being evaluated, yielding greater anxiety and a more exocentric engagement. One faculty member described the impact on presence when the instructor facilitating the simulation scenario used a detached, observational, facilitation process. When the instructor stands back and just lets someone sink or swim, I do not think it is benefitting the students very much. I have even seen the whole thing fall completely apart when the instructor does that. They completely disengage from it.

In contrast, one student described how a teacher accomplished facilitation using an embedded approach. The student recounted how an embedded type of assistance actually prevented an interruption in the scenario or what can be construed as a break in presence. “She jumped in as if she was the charge nurse as opposed to just watching us squirm. That really helped and it kept it all going like in a real situation.” Both the nature of the student-teacher relationship and the instructional method seem to impact the presence in the simulation. Data from these respondents would support that a collaborative, respectful relationship and an embedded, supportive instructional approach would promote increased engagement and an endocentric presence in simulation. This type of instructional process may also yield more positive learning outcomes in the context of an instructionally based HF-HPS.

Individual Factors Individual factors are variations that reside within the unique characteristics or tendencies of participants. A wide variety of personal traits do exist that may differentiate participants and may influence presence and ultimately learning outcomes in simulation activities. Individuals may experience simulation differently in relation to psychological, cognitive, social, physical, or other individual variations. Three categories of individual factors impacted presence in simulation in the study reported in Dunnington (2014): personality traits, emotional responses, and referential experiences. Personality Traits.  Among the multitude of variables that have been identified, there is a general assumption that a more limited configuration of attributes is more relevant and thought to mediate the learning situation. Costa and McCrae’s (1991) five-factor model is widely noted. The model consists of the personality attributes of: extroversion, neuroticism,

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Dunnington agreeableness, conscientiousness, and openness to experience or intellect. Data from this study support the connection of the personality characteristics of openness to experience, extroversion, and motivation as attributes influencing interaction in simulation. Openness to experience. The personality characteristic of openness to experience represents a cluster of traits such as imagination, attentiveness, intellectual curiosity, and preference for variety, each leading to a participant’s desire and tendency to relate in a simulated learning experience. Participants in scenario-based HF-HPS demonstrated intrinsic tendencies to either be open or to be resistant to the simulation experience. Tendencies to be open seemed to promote endocentric presence; whereas tendencies to be closed to simulation often resulted in resistance to participate and a more exocentric presence. Individual tendencies toward openness to the simulation experience are demonstrated in the words of these students. “I just have a knack for treating it like it is real. I make it vivid in my own imagination.” Similarly another student stated that he could really throw himself into pretend things and indicated how this led to immersive presence.” “Because I can throw myself into it, whether it is real or not gets a little blurred sometimes really!” Yet other students described how their tendencies to be closed to the simulation situation effectuated low immersion and exocentric presence. One student described how she “hates simulation” and how she “refuses to interact in the pretend of it all.” Another stated, “I’ve never been a role-playing person. The anxiety it causes me, I just can’t immerse myself.” A low susceptibility to presence and an unwillingness to suspend disbelief or engage can be heard in these words. Extroversion.  In common use, extroversion refers to a person that is energetic, positive, and one with a tendency to seek gratification outside oneself. At the other end of the continuum is the characteristic of introversion that implies the opposite tendencies. Individual differences between introversion and extroversion strongly influenced participants’ susceptibility to presence, attributable to the fact that scenario-based HF-HPS requires participants to role-play. However, the impact on presence also seemed dependent on the degree of extroversion. Most faculty participants described how extroverted students generally immersed more easily in simulation alluding to a tendency toward endocentric presence. One faculty member compared the reaction of extroverted and introverted students. “People that are more assertive, self -confident, and more outgoing, are definitely more comfortable acting, but students that are more introverted, find it hard to engage in it because of inhibitions.” Another described the negative impact on presence and the learning experience among students with tendencies toward introversion. “I have seen it when you put a shy person in a primary role, they

come completely unglued, completely disengage and pass on it all.” This faculty member participant also expressed a concern as to what students could learn from such a negative experience. Yet the inconsistency with this personality trait was also evident with more extreme tendencies toward extroversion. “Overly out-going people take it as a big joke and like a theatrical part; they don’t connect with it and they aren’t really focused or engaged in it.” Motivation.  Motivation is an often cited personality characteristic that is thought to influence learning and behavior. Motivation is considered to be one’s willingness to take action. In the learning situation, motivation is related to what the learner perceives as an expectation of themselves or others (Bastable, 2013). Motivation is also considered to be a factor of emotional readiness to learn (Bastable, 2013) and an important educational and instructional design consideration (Morrison et al, 2013). Motivation emerged in the study (Dunnington, 2014) as a personality trait that had some impact on presence. However, this category emerged from only 24% of 145 participants. Therefore, motivation may seem to be a less dominant factor with presence in simulation. This was a representative comment from a faculty member regarding the negative impact of low motivation on presence and the learning in experience in simulation. Sometimes it is a motivation thing. They think that they they’ll never need this because it isn’t what they are going to do in nursing. So they are dismissive about it; they resist and don’t allow themselves to become immersed or very engaged in it.”

Emotional Response.  Dynamic, scenario-based HF-HPS is a stressful learning situation. An overwhelming majority of participants (90%) reported feelings of stress and anxiety prior to and during the simulation (Dunnington, 2014). The anxiety manifested itself in two ways. In most cases, the anxiety was associated with performance anxiety related to the discomfort with being watched by instructors, facilitators, and peers. In other cases, the anxiety was stimulated by the urgency of the patient situation as would be anticipated by a similar, real patient situation. In general, performance anxiety led to a bicentric presence due to a continuous awareness of being observed in the situation. Yet, anxiety stimulated by the urgency of the declining patient status in the simulation, led to more endocentric presence that was productive to the learning situation and resembled emotions that would occur in real situation of urgency in healthcare. One student described how anxiety negatively influenced the cognitive dimension of her presence in the simulation. “This puts you in a situation where you have to perform in front of everyone, your teachers, your peers and everything. My mind just goes blank; I just couldn’t recall it in the situation feeling like everyone was watching me.” Another student’s words directly alluded to the impact of performance

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anxiety on presence in the simulation. “It was a high stress situation. I was very nervous and I didn’t want to be engaged; I was afraid to do or say the wrong thing. I was totally outside of the situation rather than feeling part of the simulation.” Yet the potential for productive anxiety from the stimuli of the simulated patient situation was also clear from these findings. In situations where students felt fear and anxiety related to the urgency of the situation, they tended to have heightened awareness that enabled a more endocentric presence. One student described it this way. “Yes there was a lot of stress and anxiety, but that is how it is in a real code. This helped me focus in more and really see how I would handle it in the real world. I felt like it was really real!” This anxiety pattern seems to reflect long established patterns identified in psychology and learning theory. It is generally accepted that lower levels of anxiety may increase readiness to learn and raise attention and arousal levels enhancing learning; whereas, high levels of anxiety may hinder concentration, retention, and task performance (Bastable, 2013). Participants indicated that high degrees of performance anxiety impaired focus, cognition, and performance. Unproductive anxiety in simulation resulted in participants feeling “frozen” or “blank” resulting in a very exocentric presence that interfered with their learning. Yet, participants who felt a more moderate stress or anxiety related to the urgency of the care situation seemed to experience heightened awareness and enhanced task accomplishment. Referential Experience.  Individual differences in prior experience or skill competencies and preconceptions about the simulation are all acquired factors that the learner brings to the simulation situation. Learners draw upon previous laboratory or clinical experiences when participating in a clinical simulation. Additionally, learners may enter the simulation encounter with preconceptions of what will unfold in the scenario based on clues from preparatory assignments and experiences, the stated purpose of the simulation, or even by word of mouth from other participants who completed the simulation. Preconceptions may mediate on the experience by limiting the process of discovery in the simulation. Additionally, Kaber, Draper, and Usher (2002) suggested that the level of experience that users bring from the real environment that serves as comparative subject matter for a virtual experience may have a significant impact on user performance in the simulation environment. Interview results (Dunnington, 2014) indicated that all of these acquired experiences strongly mediated on presence and on the learning experience in HF-HPS in various ways. Preconceptions regarding the clinical scenario seemed to lead to over attention to the selected cues, altered cue recognition, and altered clinical reasoning. Students seemed to be in waiting for the anticipated clinical event to happen. The over-attention to the anticipated data seemed to obscure recognition of other clinical data presented in the scenario.

Observation of this response also indicated that students came to what has been termed “premature closure” (Turkle, 2009) on the data rather than utilization of the expected processes of cue clustering and differential logic of clinical reasoning. One faculty member described it this way. “They are waiting, anticipating, and predicting what will happen. So they are not really engaged. It is not like real to them like when they would have to figure out what is going on.” Preconceptions, most often resulted in exocentric presence and a very limited or rote learning experience in the simulation as one student expressed. “I knew it was a code simulation. I automatically got the cart on the first symptom. It was like I was outside of something watching and waiting to just do the steps.” The impact of referential experiences in simulation was also dependent on the congruity of the simulation with the participants’ prior comparative clinical or laboratory experiences and competencies. One faculty member affirmed that “when they have similar experience in clinical, they recall it and draw on what they have learned. It helps them engage and perform in the simulation environment.” One student’s words indicated the positive impact of comparative referential experiences. “Since I hand hung blood before in clinical, it made it more real in the simulation; you can be focusing and in on the simulation thinking through how to handle the situation like it is real.” Yet a pronounced negative impact of referential experience on presence and the learning experience occurred among participants when the cues or scenario events were incongruent with real world clinical experience. This was nothing like real. I was so disoriented. I didn’t have the same triggers that cue me when I work with a real patient. I didn’t know how to get the supplies I needed; I was so flustered. I am sure that this is how I gave that medication error in the situation. I was so tense. The whole experience made me lose confidence in myself.

Entry competencies are the prerequisite knowledge, skills or attitudes that learners must have in order to fully benefit from the learning activities (Morrison et al., 2013). Most participants expressed the positive influence of entry competency on their engagement in the simulation and on the learning experience. One faculty member put it this way. “They have to have the knowledge and the skills under their belt before we can expect them to be present in what is supposed to be a simulated, real situation. Otherwise, they just stand there and watch.” On the other hand, students lacking entry competencies for the demand of the simulation had an exocentric presence and a negative learning experience. I wasn’t sure what to do. So I just stood there. I didn’t know the right action or the steps; I didn’t know all the meds. I got frustrated because I really didn’t know. I felt incompetent and I was just standing there like I was on the outside of it all.

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Group Interaction Factors A dynamic, scenario based HF-HPS is a group learning activity that requires learners to participate in a role play enactment aimed at managing the clinical situation represented. Participants are called upon to function in a group and to conceptualize and perform an unscripted improvisation of professional, interpersonal, inter-professional and intra-professional roles and behaviors in response to the unfolding clinical situation. Group structure and dynamics are naturally at play in a scenario-based simulation. Structure. Group structure concerns the organization and relation among members that organize the group. These aspects link and interconnect group members in ways that enable interactions and behaviors that focus the group on plans and goals to generate an outcome. The structural elements of group size and role emerged as factors influencing presence among participants (Dunnington, 2014). Group size ranged from three to eight participants in the study. When group size was between three and four members, all participants had active roles in the simulation and were assigned to nursing roles in the scenario. Members were more interconnected and functioned more as a team. Participants had higher levels of communication and often used a problem- solving process by consensus. This connected structure helped to increase engagement, minimize distractions, and led to more endocentric presence among the group members. In contrast when group size was seven to eight members, the group size exceeded the available opportunity for active role-taking. Four of the eight participants were often assigned to observer or back-up roles. While participation by observation may still allow for different types of learning, observational roles preclude active engagement in clinical reasoning, problem-solving, clinical judgment, or intervention. Thus a large group size necessitating observational roles induced an exocentric presence by design. Furthermore, for the group members with active roles in the simulation, immersive presence was reduced due to increased performance anxiety that was provoked by having an audience of peers in the simulation. Impact of group size on presence was evident in 100 percent of the interviews among both faculty and learners indicating the benefit of smaller groups on presence and the learning experience. Role playing requires participants in simulation to play the part as they perceive the role would be enacted in the reality of the real patient care situation. Ideally the role taken by learners in an educational simulation is the role the student is in training to learn. The degree to which participants perceived that they were able to perform the expectations of a given role and the congruity of the role status in the simulation with reality seemed to have strong inflluence on presence and the learning experience in this study. Presence was negatively influenced in this study when students perceived issues of role ambiguity or role conflict. An endocentric

presence was induced when participants perceived role congruity. Learners perceived role ambiguity when they were assigned to a role for which they were unfamiliar or had no previous exposure or experience. This seemed to cause participants to stand on the outside of the situation watching and waiting to see their position and to be given their role expectations from others. This engendered a strongly exocentric presence. Faculty participants described that when students were assigned to the role of a charge nurse for which they had little referential experience, they were often confused and stressed leading to difficulty engaging in the simulation. “They feel so on the spot, they don’t understand the role, so they just stand on the outside of it and wait for something to happen.” Likewise, students affirmed the impact of role ambiguity on their sense of being in the simulation as illustrated in this passage. I didn’t realize what I was supposed to do. We all just stood there looking at each other. The teacher had to take over and tell us what to do. So that made it much less real. We just stood back and didn’t put ourselves in the situation.

One student expressed the negative impact of the ambiguity of role expectations that she experienced being in a group of peers. “This just makes you feel like you are just a dumb student in a lab and not like you are involved in a real situation.” Dynamics.  Group dynamics refer generally to the interaction and influence among group members. Some aspects of group dynamics include relationships, cohesion, communication, coordination, patterns of influence, plans/goals and effectiveness (Forsyth, 2010). Presence of participants in the simulations in this study was influenced by cohesion, goals, and coordination. Participants either were assigned or selfselected into groups for participation in the simulation scenarios. Therefore, the level of familiarity and nature of relationships among participants varied among groups. Cohesion is considered to be a group factor leading to unity and a shared climate, identity, and commitment (Forsyth, 2010). Participants in the simulation groups that had familiarity with one another seemed to have trust, comfort, and cohesion. This increased engagement and enabled the group to function as a team. One faculty member expressed it this way. “The dynamics of the group really makes a difference in immersive presence of the whole group. It is their comfort with each other and their level of trust that makes the big difference.” Similarly one student described how group cohesion and goals influenced their focus, engagement, and coordination in the simulation. We have the best group. We all know each other really well. I felt we were a really good team. We all had the same focus; and we were all working toward the same goal. Everyone jumped right in with what they knew. It seemed very real to me.

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Yet in contrast, this nurse described the negative impact of group dynamics on presence when members were unfamiliar and cohesion was lacking. It is stressful being in a group that you don’t normally work with. You don’t know how the other person works; It makes it very hard to be a real team in the simulation, you are just feeling uncomfortable. Then it is harder to get into it, you know?

Impact of Presence Centricity on Learning Outcomes A major objective of scenario based HF-HPS is to induce a perception of and an involvement in reasoning and managing through a real clinical patient problem. The hope is also that the experience will lead to translational outcomes in clinical practice. An immersive presence is fundamental to these objectives. A linkage of presence centricity with learning outcomes emerged from this study (Dunnington, 2014). Learners who were more endocentrically present reported positively about their learning experiences and learning outcomes. Likewise faculty reported on a clear linkage of presence with learning outcomes. Students who achieved a more endocentric presence reflected on engagement in clinical reasoning and problemsolving through the clinical situation. They perceived a high degree of “responsibility for the patient outcomes” and indicated “gaining competency” in tasks required to manage the clinical problems. In contrast participants who were more exocentrically present reported perceptions of the inconsequentiality of the simulation and a low sense of responsibility for the patient outcomes. Participants who were strongly present in the simulation also reported translational outcomes to the real clinical situation. One nurse stated, “Since the simulation, I have had some really sick patients. I keep thinking back to the simulation and I am more prepared. I know what to look for; I am very cognizant of changes in the patient’s symptoms and trends.” A faculty member also confirmed the linkage of presence and learning outcomes. I think immersive presence is very important to learning. If they [students] are not present in the situation, they are not going to be processing cognitively. To get the learning out of it, they need to be making the judgment calls, making the decision about what is deterioration and what isn’t, deciding what is significant and what isn’t. If they are not immersed and present in it, they are not going to be doing any of those cognitive processes. And that was the point of the simulation in the first place.

Discussion The centricity of presence model for scenario-based highfidelity human simulation shows relationships among pedagogical, individual, and group factors and presence centricity. The model also shows a linkage of the centricity of presence

in simulation with learning experiences and learning outcomes. A more endocentric state of presence among participants in HF-HPS may lead to a more educative experience and to more positive learning outcomes. Yet, presence as a state of being in interaction is a complex phenomenon. Therefore it is possible that other dimensions and determinants of presence may exist. There also may be interactions among factors that bear on presence. The strength and salience of factors in the model as they impact the learning experience require further testing in research. The nature of presence as articulated by nurse scholars and theorists found to be operational in HF-HPS in the Dunnington (2014) study and further reported here demonstrated evidence of the impact of a sense of being there on learning experiences or outcomes. Participants who were endocentrically present reported gains in clinical knowledge, task competency, cue recognition, clinical reasoning, confidence and perceived sense of responsibility and accountability for the patient outcome. Yet, participants having a more exocentric presence, irrespective of the determinant of their state of being, reported negative learning experiences. These participants perceived high levels of anxiety, embarrassment, vulnerability, and eroded self-confidence. They also reported lack of gain in clinical knowledge or task competency. The differences in self-reported outcomes suggest that determinants of presence and the state of being present in simulation may result in either educative or mis-educative learning experiences. The determinants of presence reported here from the Dunnington (2014) study support the findings of the initial study of presence in HF-HPS by Dieckmann, Manser, and Wehner (2003). This work similarly found emotion, anticipations, expectancy, role factors, flow of events, and task related factors as influences on presence in HF-HPS scenarios. This study builds on the Dieckmann and colleagues (2003) study by raising the level of abstraction on the categories of determinants of presence perhaps allowing for a greater understanding of the relevance and amenability to technological or pedagogical considerations for enhancing presence in simulation. The centricity of presence model may also link to the existing nursing education simulation framework (Jeffries, 2012). The framework is based on five conceptual components of simulation including the interaction of teacher, student, educational practices, and simulation design characteristics as factors that interact together to iinfluence learning outcomes. Successful outcomes of simulation are linked in the model to variables in the learning context and the degree to which best practices are designed and implemented (Jeffries, 2012). Data on presence generated from the present work may build on the work in the Jeffries (2012) framework. The model presented here suggests that presence may be an additional mediating influence on learning outcomes at the articulation of teacher, student, design, and educational practices in the Jeffries (2012) model.

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Conclusion The adoption of HF-HPS is likely to increase due to the many factors propelling it use. Additionally, the potential impact of simulation on nursing education and ultimately on healthcare has the potential to be transformative if presence as articulated by nurse scholars and theorists is recognized and intimately connected with high-fidelity simulation (Dunjnington, 2014) Yet the trend toward adoption of HF-HPS has preceded the educational science to best support its use. Therefore, it is important to seek clearer understanding of factors that influence learning outcomes and to develop best practice pedagogy to assure the educative value of simulation and the most positive influence on healthcare. Dewey (1938/1987) asserted that educative experiences are those held under highly specialized conditions and in specialized environments. High-fidelity human patient simulation is indeed a specialized educational technique and learning environment. The immersive presence of participants in HF-HPS may be a central and important factor related to the learning experience and learning outcomes among participants. The key to assuring that healthcare simulation is an educative experience is to hold simulation under highly specialized conditions. The centricity of presence model may provide an adjunctive framework for research that could lead to further development of the pedagogical science for simulation in healthcare education and training. Declaration of Conflicting Interests The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this editorial.

Funding The author received no financial support for the research, authorship, and/or publication of this editorial.

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