In situ simulation training in emergency departments: what patients really want to know

Abstract

Objectives

Despite the use of in situ simulation in the emergency department (ED) for training staff to better manage critical events, little is known about how such training is experienced by patients in the ED during these simulations. We therefore aimed to explore ED patient knowledge and perceptions about staff training for emergencies, as well as their views about simulation generally, and in the ED setting specifically.

Methods

In this qualitative study, we used an interpretive approach involving video elicitation and semistructured interviews with patients who were waiting for treatment in the ED. Patients who agreed to participate were asked about their knowledge of simulation and were then shown a short video of a simulated resuscitation from cardiac arrest. We asked participants open-ended questions about their perspectives on the film and their views and about simulation training in the ED. Interviews were audio recorded, transcribed and analysed using thematic analysis.

Results

We interviewed 15 participants. Most had little or no prior knowledge of simulation training. Watching the video elicited emotional responses in some participants, and pragmatic responses concerning staff training in others, with most participants viewing simulation training as useful and necessary. Participants said that to avoid unnecessary stress, they would prefer to be notified of when simulations were occurring, and what they could expect to see and hear during simulations. Most participants predicted that they would be willing to wait slightly longer (approximately 30 min) to see a doctor while simulation training was conducted, provided they did not require urgent medical attention.

Conclusions

Patient-centred care and care partnerships between patients and healthcare professionals underpin New Zealand healthcare and medical education ideologies. This requires effective communication between all parties, as evident in our study of in situ simulation training in the ED.

Introduction

Patients have always been involved in medical education, initially as passive examples of clinical conditions or as part of a medical student's experiential learning process. Patients may now also contribute to teaching and evaluating learners, and to curriculum development.^1–3 However, using patients to learn new skills or potentially hazardous procedures raises ethical concerns,^4–7 and simulation provides an opportunity for novices to practise new skills and climb the steep learning curve to clinical expertise, without compromising patient safety.^{4 5 8} It is seen as a useful tool to reduce medical error and improve the safe delivery of healthcare.^{4 5 8} Internationally, there is considerable interest in using simulation for staff training in the emergency department (ED), and reports of improved team behaviours, decreased medical errors and improvements in attitudes towards teamwork following training.^9–11 In situ simulation has the advantage of being accessible to more staff, occurs in the clinical environment where participants work, and has the potential to identify latent safety issues.¹²

However, potential disadvantages of ED simulation training exist for patients and their families, which may require preparation and consent for those who may see or overhear the simulation.¹² Perhaps surprisingly, however, these issues have rarely been explored. In their survey of patients’ preferences for care providers, Graber et al¹³ found that for some procedures, such as lumbar puncture or central line placement, patients preferred not to receive care from medical students who have not performed the procedure before, even if the student had undertaken simulation training for the procedure. This could suggest that patients do not value the simulation experience of healthcare professionals. We suspect instead that Graber et al's findings¹³ raise more questions than answers about patients’ knowledge and values concerning simulation training generally, and in situ simulation in particular. What are ED patient perceptions about staff training for emergencies in general? What do they know about simulation training? What attitudes do patients hold towards ED in situ simulations? What information do ED patients need about in situ simulations?

The present study sets out to answer these questions, and to help contextualise Graber et al's findings.¹³ Perhaps more importantly, the findings can inform future in situ simulation training programmes in the ED and indeed, in other healthcare contexts, about the potential emotional and psychological impact and information needs of patients.

Methods

Ethics

The study was approved by the University of Auckland Human Participants Ethics Committee (Reference 9296) and by the Waitemata District Health Board Awhina (RM0980712450).

Study overview

We selected two New Zealand public hospitals where in situ simulation ED training is regularly conducted as field sites for this study. We asked ED patients to participate in an interview after their initial assessment and treatment, while they waited for investigations or results. We first asked participants about their general knowledge of simulation training, and then showed a short video of a simulated resuscitation. After the video, we asked participants about their perspectives on the video and about in situ simulation training in ED.

Study setting and participant selection

The Waitemata District Health Board in Auckland, New Zealand has two EDs, and patients from both the North Shore and Waitakere EDs were invited to participate. Participants were selected using a combination of convenience and purposive sampling, so that the study included females and males from a range of ages and ethnicities, with different reasons for attending the ED. Inclusion criteria were patients over 16 years of age, waiting for tests or results after assessment by clinical staff. Patients were excluded if clinical staff or the interviewer judged that they were distressed, too unwell to participate, confused, unable to give informed consent, or unable to read, speak or understand English. On data collection days, the interviewer (KMY) liaised with clinical staff to identify potential participants. Eligible patients were given an information sheet, and informed consent was sought, including consent to audio record the interview.

Study design

Video elicitation was undertaken during semistructured interviews. We explored patient perceptions about staff training for emergencies, knowledge about patient simulators and perceptions about the advantages and disadvantages of using patient simulators for training using questions 1–4 of the semistructured interview guide (see online supplementary appendix 1). These questions were followed by a video viewing (described below), which was followed by the remaining interview questions (see online supplementary appendix 1). This method of data collection is similar to photo elicitation, whereby participants are asked to take photographs about a given subject and then describe the meanings they associate with each photograph.^{14 15} We adapted the photo elicitation mode for video, whereby participants’ meaning-making was explored after they watched a video provided by the researcher. In so doing, we are following standard visual anthropological approaches to understanding participant translation and meaning-making through video documentation.^{14 15}

All participants were shown the same video (5.00 min duration). The video demonstrated a simulation exercise of nurses and doctors participating in a cardiac arrest simulation using a manikin, with an educator giving information. In the video, current resuscitation algorithms were followed, and the manikin was successfully resuscitated from ventricular fibrillation after two defibrillations. The nurses and doctors in the video had consented for it to be used for the study. The video, which the participant watched on a tablet computer, was introduced by statement 5a (see online supplementary appendix 1), and showed the simulation event (but not the subsequent staff debriefing). Questions following the video explored patients’ feelings, their perceptions about simulation and their views on some practical matters related to holding simulations in the ED setting, as shown in questions 5b-12 (see online supplementary appendix 1).

Data collection

We planned to interview a minimum of 12 participants, then continue the interviews until we reached data saturation.¹⁶ Interviews took place in the patient's cubicle within the ED to ensure participant privacy during the interview while also enabling the ED clinical staff to have ready access to the patient if needed. There were contingency plans in place to manage clinical or other events, or disclosure of clinically relevant information during the course of the interview. Demographic data including age, gender and ethnicity were recorded at the start of each interview.

Data analysis

We used an interpretive approach, following Yanow and Schwartz-Shea,¹⁷ to analyse the interview data. An interpretive approach is a form of research whereby the researcher seeks to understand human experience as meaningful and historically contingent.^{17 18} We chose an interpretive approach to generic qualitative research in order to apply in-depth analysis to the patient perspective. All interviews were transcribed verbatim. Transcripts were then entered into the qualitative software analysis package NVivo10 (QSR International). The research team consisted of two senior clinicians with experience of working in an ED (KMY and JMW) and a clinical educator (CSW), with all team members having qualitative research experience. Thematic analysis was initially undertaken by KMY following Creswell.¹⁹ Data were analysed for significant statements and quotes, and clusters of meaning were developed into themes.¹⁹ Common themes and patterns were elicited, while individual variations in participant experiences were noted. The initial research team (KMY, CSW, JMW) cross-checked the thematic analysis to ensure rigour during this stage of the analysis and once analysis was completed, it was checked again by a new member of the research team (TJ) and the themes were again adjusted. When participants referred to specific durations in response to questions about acceptable waiting times during training, we translated this into minutes so that the median and range could be described. Demographic descriptions of the patient group were also collated.

Results

Fifteen ED patients across the two sites participated in this study. Their ages ranged from 22 to 88 years, 8 (53.4%) were female and five ethnicities were represented (predominantly New Zealand European). There was a broad variety of presenting complaints (see table 1). Interviews lasted 15–30 min.

Table 1.

Study participants

Participant number	Gender	Age (years)	Participant self-identified ethnicity	Patient's view of presenting complaint
1	Male	66	Maori	Weak heart
2	Female	32	NZ European*	Pregnant and bleeding
3	Female	76	NZ European	Fainting fit
4	Male	75	NZ European	Fall
5†	Female	35	NZ European	Fall injuring shoulder
6	Female	41	NZ European	Chest pains
7	Male	32	Maori	Collapse and sore arm
8‡	Female	22	NZ European and Maori	Asthma
9	Female	88	European (Austrian)	Breathing problems and fever
10	Female	52	NZ European	Acute chest pain
11	Female	54	NZ European	Diabetes type 1 and dehydration
12	Male	33	Samoan	Kidney stone
13	Male	77	NZ European	Dizziness and problems talking sense—better now
14	Male	75	NZ European	Frightening allergic swelling and rash
15	Male	49	NZ European	Kidney stones

*NZ, New Zealand; NZ European is also often referred to as Caucasian or Pakeha.

†Participant 5 did not complete the interview due to her feeling unwell, but her answers to Questions 1–4 are included.

‡In Participant 8's interview, her partner joined the discussion, and his comments are included where relevant (with his informed consent).

Thematic analysis identified five main themes: competency in holistic patient care; simulation in reality; patient needs take priority; video as catalyst; and patient choice of ED. These themes are interconnected, as are their subthemes. Table 2 indicates where themes significantly overlap or connect. The key messages concerning each theme are outlined in table 2 and then discussed below, with supporting quotes for each theme provided in a separate table (box 1–5).

Table 2.

Main themes

Theme	Subtheme	Key messages from (patient) participants
Competency in holistic patient care	Practical experience Technical skills Compassion Timely care	▸ Practical experience and mentoring for staff is important when learning to manage emergencies ▸ Managing emergencies is not just about technical competence ▸ If kept informed, ED patients are willing to wait longer for care during simulation training
Simulation in reality	Real pain and risk Potential to harm Patient predictability	▸ Simulation is a rehearsal for real-life emergencies ▸ Manikins do not have urgent or real needs ▸ Patients have unique and unpredictable needs ▸ Patients prefer that staff practise first on manikins
Patient needs take priority	Prioritisation Timely care Patient safety Information flow	▸ Patient needs should take priority over simulation training ▸ Patients should be informed and told what to expect if a simulation is taking place
Video as catalyst	Simulation exposure Reflection Competency in holistic patient care	▸ Video of simulation evokes both emotional and pragmatic responses in patients ▸ Video of simulation evokes reflection on own present situation and past experiences ▸ Video of simulation demonstrates potential staff performance and capabilities
Patient choice of ED	Competency in holistic patient care Patient safety Timely care	▸ EDs that use simulation to practise might provide better patient care and improved competency ▸ EDs perceived to have safe care and competent staff are preferred ▸ Simulation may or may not lead to improved ED care

ED, emergency department.

Box 1. Competency in holistic patient care.

Practical experience and technical skills

“Obviously there's got to be some practical…they've gotta, like, practise on patients. ‘Cos that's where you're gonna get your proper information you know. Like rather than in theory. So both … need to know their stuff and the theory, and to put it into practice.” (female, 54 years)

“Just on the real thing I guess it's a bit like getting blood out of patients. You just put them on the front line and get experience from the live bodies … it might be a bit cynical but ah…” (male, 75 years).

“I imagine buddying up with someone who's experienced in here and going through, you know, reading screeds of policies and procedures before they start and being mentored by someone who's experienced in the emergency department, working alongside them, depending on what their level of experience is, for a week or two. And then, you know, going out on their own when they've...I imagine they have to [have] some sort of, I don't know, I've never worked in an emergency department, some sort of competencies or something to show that they're competent in this area” (female, 52 years).

“I guess a lot of it just comes with experience and dealing with the situations as they come. And obviously in their training with the many years of training that they've had, they get the experience there and the practice. … So really I guess it's just a matter of when they're junior and starting out, teaming them with someone who is a bit more experienced, and doing observations as well and seeing what's going on. And that's often the best way to learn things” (female, 32 years).

“I think it would be comprehensive training about medicine and the equipment they are using, the disciplines, and …[being] prepared to work as a team, which means there is leaders and followers” (male, 75 years).

“..I guess a mixture of lectures, workshops and on the job experience really. Yeah. Working with people who have more knowledge” (female, 35 years).

Compassion and timely care

“I think they're trying to be effective and professional and as fast as they can be under the sort of demands of the work. So yeah, given the resources and time frames, they're pretty good. I think they're trying [to] be as caring as they can but within the timeframes. So they can't exactly spend too much time with patients. Which is completely understandable” (male, 33 years).

“I think they are doing alright as it is. They're calm and collected. So if you are agitated they calm you down somehow, you know. They're not rushing around making noise” (female, 88 years).

“Well to make it more comfortable for the patient ah, the beds are too damn hard and it's too cold in there” (male, 75 years).

Box 2. Simulation in reality.

Learning: simulation is a rehearsal for real life emergencies

“Actually to learn on a manikin would probably be better than learning on a real person, I believe (laughs)” (male, 33 years).

“…you don't want to be practising on patients. You wanna be fully trained when you get to them” (female, 41 years).

“... It does give the staff more practice, doesn't it? … They can do that anytime, whereas they don't really know when there's [going to be] a patient, you know” (female, 76 years).

“But it's good just to have the sort of practice on there but for the standard stuff, maybe. I'm not sure.... They're familiar with the situation and so they're better prepared” (male, 33 years).

“I think they're useful to a degree. Certainly to get your skills. You know, practise your skills, your basic skills so that when you do have to put it in to practice in an emergency you're a lot clearer about what you have to do. The procedure” (female, 52 years).

“Well it takes away the anxiety of making mistakes. And I think it gives them a sense of being able to practise in a relaxed sort of way, using what they've already studied” (male, 75 years).

Real pain, risk, potential to harm and patient predictability

“For starters you can't kill them, cos, well, it's fake! (laughs) um...well (clears throat) if you do the wrong thing, well, it's not going to have a bad effect—is it?—on a human being it's gonna have a bad outcome.” (female, 22 years.)

“[it's about trainees] not being anxious at that point in their training about the client reaction [because it's a manikin]” (male, 75 years).

“I guess the disadvantages are that perhaps a manikin doesn't always react the same as … a person. So it's probably not exactly the same as dealing with a real life trauma” (female, 35 years).

“They might be okay to practise on but when you go get to a patient I think it would be different. Yes. It is unpredictable what a patient is going to do next. But with a dummy it's just…” (Female, 36 years).

“It might not go as smoothly in real life. And that just sort of only prepare[s] [trainees] for things to be going as it was in the simulation, and not for other sort of things to pop up and catch them off guard. And they're not really prepared to be, sort of, creative, if need be” (male, 33 years).

“Well every patient is unique. So that the manikin is only just a sample. But every human being reacts differently to every situation. … So I think having done the manikin training, I think they have to then recognise that every person will be reacting to their anxiety, their pain, their fear, their uncertainty, differently” (male, 75 years).

Box 3. Patient needs take priority.

Prioritisation and timely care

“I wouldn't really like it. Ah, yeah. Especially if you were waiting for things to happen and you kinda think ‘Hello? I'm here’” (female, 41 years).

“If the ward's really busy and they get, obviously I wouldn't like the fact that they get called away from a real patient to go and do a simulation. If it happened during a quiet patch and if a real emergency did arise, if they were able to leave, obviously cos it's, the dummy, the manikin, they could leave it straight away, then I think it would be alright” (female, 32 years).

Patient safety and information flow

“It would be nice to be told there was an emergency simulation going on next door, not the real thing. Because then immediately I would relax more” (female, 52 years).

“I think it would be just courtesy to let someone know it's not a real life … that way I won't be, like, freaked out by hearing all the stuff that's going on” (male, 33 years).

“I guess it would just be nice to know that something is going on especially when you hear all the buzzers and everything going. … You just assume it's a real person” (female, 32 years).

“…what to expect in terms of the beeping and all the noise, people coming and going, how long it would take” (male, 49 years).

Box 4. Video as catalyst.

Simulation exposure

“It seems like they were doing everything they could you know, I'd be happy if I was in trouble like that and I was getting that kind of service. I would think that was good” (female, 54 years).

“The girl with the ponytail in the black, well she should have been to the side so when they had more room to move around instead of having to walk around her” (female, 22 years).

Reflection on own present situation and past experiences

“I was reading last night … correspondence we got...I was just about to sign, if you sort of collapse you've got to sign to say whether … you want them to resuscitate you” (male, 75 years).

“Just glad that it wasn't me” (male, 77 years).

“Well actually it makes me think of my husband because he died of a heart attack. But it was the same year in 2000, in February, my grand-daughter's husband died of a heart attack, at 28. But then it was my daughter's husband [who] died of heart attack in August, and my husband died in October of heart attack” (female, 88 years).

Box 5. Patient choice of emergency department.

Holistic patient care

“They would probably be a little bit more prepared, maybe have an edge on if something went wrong, and so for instance, if I was in the emergency, they'd be better prepared for it” (male, 33 years).

“I just think it's a necessary tool. … it's something that's needed to improve service, you know, like health. I think it is necessary because people aren't going to get the experience, like if you don't get a live case, you know, that you're picked to work on. How are you going to know what to do if something does crop up?” (Female, 54 years).

“There is always the fear in the back of the mind: do these, like I'm an old man now, do these young people know what they're doing? So I think if I thought that they were simulation-trained, I'd feel the same about a pilot. I would like to fly with a pilot who'd been in a simulator many times. Rather than being in a plane and be told this is the first time he's flying (laughs)” (male, 75 years).

Patient safety

“If I'd known about the training and it had improved the competence level of the staff and the care for patients then definitely yes I'd go for that one.” (Male, 49 years).

“Well there are a lot of mistakes made in hospital and ah, and ah, the safer one” (male, 75 years).

Competency in holistic patient care

Many participants had not previously considered how staff practise for emergencies, or even whether staff need ongoing training. One participant thought that staff manage all types of emergencies frequently. Participants recognised that theoretical knowledge alone does not prepare staff adequately for managing emergencies and that practical experience is essential (box 1). Older participants (66 years old or more) reported that they thought it was appropriate for staff to practise with patients, and that staff do practise with patients. However, they would prefer if staff trained first with manikins (box 2). Many participants perceived on-the-job experience and mentoring as an important part of how ED doctors and nurses practised for managing emergencies. The central theme that emerged concerned competency in holistic patient care. Regardless of the training mode utilised in the ED, participants thought staff should not only have practical experience and compassion, but also should learn technical competence and professional treatment skills. They saw these three elements as equally essential to informing holistic patient care. Describing these elements, participants said they want staff to be ‘friendly’, ‘compassionate’, ‘speedy’ and ‘effective’, and to provide ‘professional treatment’ while considering patient ‘comfort’ (box 1).

Most participants said they would be willing to wait up to 30 min longer than usual for themselves or a family member/friend to see a doctor, while an ED simulation was in progress, as long as the patient had been assessed by a nurse and was in no immediate danger or in pain. However, the range of acceptable waiting times was wide (0–120 min) and some participants said they would want friends or family seen sooner (median: 10–15 min longer), compared to themselves (median: 20 min longer). One 41-year-old woman felt she “wouldn't want to wait at all”, but other replies ranged from “no more than 5 minutes” (male, 75 years) to “maybe up to two hours” (female, 22 years).

Simulation in reality

Most participants reported having very limited knowledge or experience of simulators. What little knowledge they did have was reportedly gleaned from the media, movies, participation in First Aid courses that used simulators or talking to family who ‘knew’ about them. The youngest study participant, a 22-year-old woman, said that her mother had told her manikins “feel squishy.” Others had seen simulators on television; “They can get quite high tech. I've only seen the surgery ones on the news where they can...wave and move their hands. You can actually pretend you're doing something to someone” (female, 41 years).

For many, watching the study video provided them their first exposure to a simulation manikin and significant (although simulated) emergency event. Many participants interpreted simulation as a good and safe way to rehearse for emergencies without causing harm to patients. They described what they perceived to be advantages and disadvantages of simulation. Perceived advantages included that it was safer to practise on manikins, and manikins would be more available than patients. Disadvantages included that they would not react like a real person, as real people are unique and less predictable and would feel pain. One participant commented on her experience of staff having multiple attempts to insert an intravenous line, and the advantage of staff practising on a manikin: “They have to poke again to find it and still get the wrong place. Then they have to go to the other side to find it. On a human that hurts! I have suffered that. But on a manikin it's not going to feel a thing” (female, 22 years). This tension between a manikin that cannot be harmed and patients/participants who can be harmed—and who may even have previous experiences of being harmed—was immediately apparent to participants (box 2). Similarly, participants interpreted that simulators are generic and more predictable than people, demonstrated by comments that real patients would have unpredictable or unique needs.

Patient needs take priority

Some participants anticipated that if they observed an ED simulation, it would not cause them concern, and that such observations could make patients feel encouraged or safe. However, participants indicated that they would feel stressed if they thought a real resuscitation or emergency was occurring, possibly making them feel “a little sad” (male, 32 years), “ragged” (female, 88 years) or that “…anxiety levels would rise a little more” (female, 52 years). A few suggested that ED staff training should be in a more private setting such as “...curtained-off and screened” (female, 52 years). Some participants felt strongly that the needs of ED patients should remain paramount, as seen in box 3.

Many would want to be informed that staff were training using simulation or a manikin, mostly because they would feel more stressed if they thought it was a real emergency. As seen in box 3, informing patients in the vicinity that an ED simulation was happening and what they might see or hear, was felt important, in order to mitigate the stress that some might feel if they thought it was a real emergency. A few would want to be reassured that all their “needs were being met” (female, 41 years) or that they would be “alright” (male, 66 years) while the ED simulation was going on. They indicated that it would be important to reassure patients that their care would not be compromised while the simulation took place, and that care back-up plans were in place to meet the needs of ED patients during simulation training.

Video as catalyst: feelings about the video showing a cardiac arrest resuscitation simulation

The video, which showed a cardiac arrest simulation performed according to current algorithms, was initially responded to by participants with comments assessing the skills and actions of the staff displayed in the video (see box 4). Five participants expressed that watching the video of the simulation brought up memories and feelings about their own experiences or situation. The cardiac arrest scenario seemed particularly evocative to older participants (box 4).

Patient choice of ED

None of the participants said they would avoid an ED that used simulation to practise for emergencies, despite recognising the potential patient disadvantages (potential for delay to their care and increased patient stress) in doing so. Many participants said they would prefer an ED that used simulation to one that did not, as they thought the quality of emergency care might be better (see box 5). Some felt, for example, that these ED staff would have had “more thorough training” (female, 52 years), would “probably do a better job than the ones that didn't practise” (male, 32 years), or that they might get a “better result” (male, 66 years). A few participants were less enthusiastic, feeling that proof of safety and staff competence would be more important, with one participant challenging the assumption that simulation was the best way to train (see box 5).

Discussion

ED patients who participated in this study provide a critical lens on how the ED as a training site might be experienced by patients within that environment. The findings from our study suggest that the experiences of patients, specifically in relation to ED in situ simulation training, are important because patient exposure to such training does inform their overall impression of the services provided, may contribute to their stress levels and may inform their healthcare-seeking practices, including the amount of time they are willing to wait for care.

Despite evidence that ED waiting times are an important contributor to patient satisfaction,²⁰ most participants in our study were prepared to wait some extra time to see a doctor while the ED simulation was in progress as long as they were informed that the training was taking place. While this finding is based on the predictions of just 15 people, it does, however, suggest that future quantitative research could usefully explore this in a larger population.

The video of the simulation training elicited an emotional response from some, and opinions on staff behaviours from others, suggesting that this may happen if patients witness an in situ simulation. These factors need to be considered when planning such simulations in the ED. Techniques for informing patients about the purpose and process of ED simulation could be specific for a particular simulation, such as informing ED patients in the vicinity of what they might see or hear, and how the training may affect their care. Other media for patient education, such as pamphlets, online videos, news reports and documentaries, could also be considered and potentially made available for ED patients.

An important element in the simulation training is staff debriefing at the conclusion of the event to make sense of what happened, which may or may not be seen or heard by patients. Our study demonstrates that ED patients who witness a training event may make judgements on staff performance based on what they see and hear, even when they may not have a full understanding of what happened.

Many qualitative studies have shown that patients often define the quality of a health service through patient-centred care, so that quality to some may mean having physical and emotional needs met, feeling heard, feeling respected and receiving individualised care.^{21 22} Staff and patients may have differing views on what constitutes good quality care.^{21 23} In one primary care study, doctors and patients both ranked clinical skill as the most important determinant of quality, but patients ranked provision of information as next most important, whereas doctors rated this sixth.²³ Qualitative studies have shown that ED patients often feel stressed, vulnerable and anxious, and that patients appreciate staff who care for their psychosocial and emotional needs.²⁴ Our study reinforces the message that patients appreciate kind, compassionate care. Simulation might be seen by its enthusiasts as a useful tool to reduce medical error and improve the safe delivery of healthcare, providing an opportunity for novices to practise new skills without compromising patient safety.^{4 5 8} However, patients with a focus on the experience of care may not view this as quality improvement if patient-centred care, communication and emotional support are inadequate.²¹ Patients in our study expressed some concerns that training only for technical skills or algorithm-led behaviours, a potential criticism of simulation-based training, was not sufficient in itself to ensure holistic patient care.

Strengths and limitations

Using the framework developed by Liamputtong,²⁵ criteria for rigour in qualitative research include credibility/authenticity, transferability/applicability, dependability/consistency and confirmability/neutrality. In this study, patients were interviewed in the ED, complete with noise and interruptions, aiming for an authentic setting. Bracketing is a process by which a researcher tries to set aside their personal beliefs about a phenomenon.¹⁹ The interviewer (KMY) is an emergency physician and educator who believes in situ simulation has been a very useful teaching and quality tool in EDs, but she tried to set these beliefs aside when designing the questionnaire and conducting the interviews. However, it is possible that verbal or non-verbal clues of enthusiasm for simulation, and the potential doctor-patient power relationship, may have affected participant responses and interpretation of interview data. Regarding transferability and generalisability, the participant sample is small but demographically diverse. Given that participants were recruited from two EDs and that we reached thematic saturation across the two sites, this would suggest that the findings may be generalisable to other ED settings. There is debate about the best sample size for interview-based qualitative studies.^{16 26} By transcribing interviews and analysing themes as interviews progressed, we found that in 15 interviews no new themes emerged in the final 3 interviews, suggesting that saturation was reached.²⁶ Therefore, we do not interpret the small sample size as a limitation of this study.

We acknowledge that some participants described an emotional response to the video. We had considered that the material shown was less graphic than many events shown on television, and life support training programmes using manikins that are widely available to the public. While the video produced valuable insights for our research purposes, and ethical review committees had full details of the interview and video, we acknowledge that we could have provided more information prior to asking participants to view it. The video was, however, shown in a controlled and supportive environment and phone numbers of the researchers and the Ethics Committee were provided to participants so that following the study they could voice any concerns that they or their families may have had, but no one made contact about any concerns.

Conclusions

Given that New Zealand's health system, like many others, is underpinned by ideologies of patient-centred care and care partnerships, it is imperative that clinical training continues to check in with patient experiences, perceptions, knowledge and attitudes. Informing ED patients what to expect if simulations occur in the ED, and offering reassurance that patient care will not be compromised, are critical to promoting positive patient experiences.