By: Charlotte Alexander
The ideal example of full immersion (admittedly fictional) would be the Star Trek ‘‘holodeck’’, in which one literally cannot tell the difference between the simulated experience and real life.
– The Future Vision of Simulation in Healthcare – David Gaba
In 2004, Gaba had us imagine a simulation so immersive, one cannot tell the difference between the simulated experience and real life [1]. More than twenty years later, I am facilitating a simulation that unashamedly possesses little physical resemblance to real life – a visually enhanced mental simulation (VEMS). Our ‘patient’ is a laminated paper cut out, representing a child with anaphylaxis. An experienced paediatric emergency nurse is ‘putting on monitoring’ by drawing a saturations probe and blood pressure cuff on the ‘patient’ using a whiteboard marker. Vital signs are displayed on an iPad ‘monitor’. While standing next to the team, I verbalise the physical signs – an urticarial rash, stridor and respiratory distress.
To an outsider, observing the scene, this would be a far cry from the holodeck Gaba sought. Yet I see a group of learners who appear completely immersed in the experience. It may not look real, but the decision making, the teamwork and the emotion in the room, feels real. Is this simple simulation technique unleashing the most powerful simulator on the planet – our own minds?
First, some definitions.
Immersion
Immersion can be defined as, “the subjective impression that one is participating in a comprehensive, realistic experience” [2]. Physical resemblance is only one component of this immersion. Dieckmann et al. suggest that a sense of realism relies on three modes of thinking – physical, semantical, and phenomenal [3]. Physical realism relates to structural similarity. The airway cart in the simulation looks and feels like a real airway cart. Semantical realism relates to a shared sense of what is true. The team knows that the patient who isn’t breathing becomes hypoxic. Phenomenal realism relates to a participant’s emotions and beliefs. The airway team feel the urgency of securing the endotracheal tube. Creating immersive simulations is more complex than simply creating physical resemblance, and relies heavily on clinicians’ prior experience; their stored patterns of sensory and affective stimuli trigger enactments (or ‘simulations’) in their brains [4]
Engagement
Engagement in simulation can be defined as “a context-dependent state of dedicated focus towards a task wherein the learner is involved cognitively, behaviourally, and emotionally” [5]. Cognitive relates to the depth of thinking – how much thought a learner invests in a task. Behavioural relates to the actions participants take – consistently attending simulation sessions, putting effort into the simulation. Emotional referred to a learners affect – feelings of interest, stress, joy or conversely, boredom. This framework emphasises that engagement is context dependant state, rather than an inherent trait of an individual learner [5].
So, how are VEMS immersive and engaging?
When I watched the VEMS scenario described earlier, the participants appeared completely immersed and engaged. This was despite – and perhaps because of – the lack of physical resemblance. I see the drugs nurses deep in thought, cross checking the dose and concentration of the adrenaline infusion. The airway doctor and nurse decide to prepare for intubation, in case of further deterioration, and start going through their airway checklist. The team leader is providing recaps to the team and planning their next steps. In the debrief, participants expressed the level of stress they felt when their laminated patient wasn’t responding to intramuscular adrenaline. There were no complaints from participants about how things would be different ‘in real life’. This appears to be a paradox – intense immersion and engagement, despite reduced physical realism.
To better understand how VEMS can achieve this, we can look at insights provided by those using VEMS frequently. A recent study provides us with recommendations for the design and delivery of VEMS, based on analysis of interviews with both participants and facilitators of these simulations[6] Their findings are instructive; VEMS was flexible, less ‘scary’, unexpectedly engaging, and supported a sharper focus on teamwork.
One striking insight they shared: manikins are confusing. One study participant commented “we’re so used to the manikin sometimes not doing what we expect it to do or not completely trusting the mechanics of the manikin…”[6] The authors assert that a manikin should not be a default modality for healthcare simulation and may even be a barrier to the ‘mental enactments’ triggered by simple stimuli. Exhortations to ‘treat the manikin as if it were real’ don’t work when learners don’t trust what they are seeing. Given their findings, the authors argue that using a manikin should be conscious choice, for a specific reason, not the default.
So where to from here….
We find ourselves with a paradox that flies in the face of Gaba’s vision of a ‘holodeck’ simulation. These observations call for a better understanding of how we create immersion in simulation, with empiric research. In the meantime, perhaps we should muster more curiosity; ask our participants what supports their immersion and what detracts from it, instead of merely telling them to suspend disbelief. Maybe we should step out from ‘behind the glass’ and stand next to participants to quietly and consistently provide those verbal cues. Maybe we should sometimes observe our simulations through the lens of engagement, watch for triggers and barriers to that engagement, and reflect on our design and delivery choices.ms improvement.
About the Author
Dr Charlotte Alexander is an emergency physician, currently working as the Education Fellow at Gold Cost University Hospital in Australia. Her interests include simulation-based education and clinical skills training. She can be contacted at Charlotte.Alexander@health.qld.gov.au
References
- Gaba, D.M., The future vision of simulation in health care. Quality and Safety in Health Care, 2004. 13(suppl 1): p. i2-i10.
- Dede, C., Immersive interfaces for engagement and learning. Science, 2009. 323(5910): p. 66-9.
- Dieckmann, P., D. Gaba, and M. Rall, Deepening the theoretical foundations of patient simulation as social practice. Simul Healthc, 2007. 2(3): p. 183-93.
- Barsalou, L.W., Simulation, situated conceptualization, and prediction. Philosophical Transactions of the Royal Society B: Biological Sciences, 2009. 364(1521): p. 1281-1289.
- Padgett, J., et al., Engagement: what is it good for? The role of learner engagement in healthcare simulation contexts. Adv Health Sci Educ Theory Pract, 2019. 24(4): p. 811-825.
- Brazil, V., Speirs, C., Scott, C., Schweitzer, J., Purdy, E. , Recommendations for the design and delivery of Visually Enhanced Mental Simulation: insights from participants and facilitators. Journal of Healthcare Simulation, 2025.
Note – The attached image is AI generated
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