An Immersive Mirror: A Descriptive Study of Peer Observer and Active Participant Experiences in Simulation

An Immersive Mirror: A Descriptive Study of Peer Observer and Active Participant Experiences in Simulation | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article An Immersive Mirror: A Descriptive Study of Peer Observer and Active Participant Experiences in Simulation Naomi Tutticci, Sandra Johnston, Joanne Ramsbotham, Karen Theobald This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7042715/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 02 Dec, 2025 Read the published version in Advances in Simulation → Version 1 posted 9 You are reading this latest preprint version Abstract Background There is limited evidence and humanistic thinking about the thoughts and reactions of peer observers during nursing simulation. An increased understanding may provide new insights and opportunities to advance therapeutic relationships and holistic care. This study explored peer observer and active participant thoughts during simulation to better understand how shared learning experiences transform and improve nursing practice. Methods A qualitive descriptive design generated data via peer observers and active participants’ self-reported experiences from pre-registration second-year, nursing students. Responses were synthesized and analyzed using reflexive thematic analysis. Results From 175 peer-observer accounts, four codes were generated and synthesized into three themes: Observer self-critique and critique of others; observer empathy and affect; and observers’ outsider perspective. Six codes were generated from the analysis of 234 active participant accounts analysis and synthesized into three themes: participant affect; participant cognition and participant confidence. Conclusions The peer observer role can experience simulation as an immersive and emotive encounter that may indicate active and deep learning is occurring. Simulation learning design should prioritize the identification of empathy experienced by observers for the participants and explicitly include it in cognitive processing undertaken during simulation debrief. Linking the experience of empathy with nursing theory in simulation is a powerful learning tool. Peer observer simulation nursing pre-registration empathy holistic Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 INTRODUCTION Many nursing students have limited experience caring for, and an understanding of patients lived experiences. As faculty, we need to be mindful of purposefully balancing learning in the intuitive art, scientific knowledge, and technical capability domains of nursing when preparing undergraduate nursing students. 1 Simulation provides a safe, reality-based and interactive environment for students to practice their abilities, make mistakes and repeat the process leading to mastery. 2 – 3 This provides an opportunity for students’ active participation and direct monitoring by their peers, improving their understanding of care provision because it is seen and applied. 3 Holistic nursing simulation combines simulation pedagogy with holistic nursing philosophy promoting students’ self-awareness and a grasp of others’ perspectives in a caring and healing relationship. 4 The active participant experience in simulation has been extensively evaluated and is largely understood with recent refinements to simulation design evolving as experiential learning for both participant and observer is prioritized. The active participant and observer simulation model is commonly used, allowing participants to immerse themselves safely, in real-world clinical scenarios. 5 In this simulation model, observers typically provide feedback during debriefing with facilitator guidance. 6 To date, simulation design and implementation have focused on optimizing this real-world, simulated experience. This is not disputed as being of value as it is essential for improving the student learning experience. Little is known however about peer observer thoughts during simulation and further how an understanding of this phenomenon may translate to improvements in simulation design and implementation. 2 Peer observers learn vicariously in simulation-based experiences (SBE) but also may experience similar thoughts and reactions to active participants. This paper argues that peer observers could experience both vicarious and immersive learning, a position not universally evident in contemporary literature. 7 Similar thoughts and reactions by both peer observers and active participants suggest an emerging simulation phenomenon, worthy of further exploration if such an approach optimizes understanding of each other as whole beings. 4 BACKGROUND Simulation is highly valued by educators as a pedagogy to safely and effectively prepare nursing students for practice. The experiential nature of simulation allows students to test their understanding of person-centered, holistic care in the context of the scope of practice, skill acquisition, teamwork, and communication. 8 Within such immersive experiences, soft or interpersonal skills are the cornerstone of person-centered care, 9 often evident in effective communication that requires the nurse / student to understand what it means to be human: capable of expressing warmth and respect, treating patients and caregivers with dignity and compassion, genuineness, and empathy. 10 , 11 Experiencing these aspects of humanness, within an immersive, yet safe and controlled simulation can better equip nursing students to deliver sensitive and holistic care. Full immersion in simulation is characterized by the participant’s deep and holistic involvement of senses, emotions, thinking and behavior. Immersion describes the level to which the learner becomes involved in the simulation; a high degree of immersion indicates that the learner is treating the simulation as if it were a real-life (or very close to real-life) event. 12 Deep immersion is more likely when the fidelity of the simulation closely aligns with reality (emotional, conceptual and physical) as well as the participant´s perception of realism. 12 Student engagement in simulation is enabled by peer presence with contribution and expertise from experienced facilitators. Barriers to engagement in simulation have been reported as arising from student anticipatory anxiety, poor preparation, and lack of skilled facilitation. 13 Simulation can incorporate both an ‘active participant’ and ‘peer observer role’, the active participant is required to immerse themselves in an allocated role, in the simulation scenario, whilst the observer is typically physically distanced from the scenario, whilst documenting observations via a worksheet or cognitive aid that focusses attention and scaffolds thinking. 14 , 5 While the participant experience of simulation has been well documented, what is less understood is peer observer reactions during simulation. Observation of simulation aligns with vicarious learning principles. Vicarious and immersive learning have appeal for the adult learner, with benefits attributed to both forms of learning. 15 Vicarious learning or learning from the behavior of others is a concept derived from the work of Bandura. 16 Watching your peers in the simulation observer role can provoke learning through an alternate mode and reduce the cognitive load associated with immersive learning, particularly when new skills are being acquired. 17 Numerous advantages are associated with the peer observer role, including learning from an objective position, opportunities for reflective practice and increasing student participation in the experience. 18 Conversely, observation as learning is not considered to be a true form of experiential learning as active participation is required. 18 Conceptually, vicarious learning via observation of peers during simulation has been posed as more valuable than active participation especially when combined with evaluative peer feedback. 19 Learning through the observation of others is a known concept but it has not been investigated thoroughly as an aspect of experiential learning in simulation contexts. 18 , 20 Understanding how quality SBE learning outcomes are obtained is obscured when the peer observer role is poorly reported and studies rarely distinguish between active participant and observer 7 , 5 as this limits a deeper conceptual understanding of the shared functionality of the roles and the distinct differences. To optimize learning when physically separated whilst maintaining an intellectual connection with the scenario, a structured approach to peer observation is often used, such as a worksheet. 14 The authors postulate that if peer observers are given little direction on their role or are not provided with a tool that directs their action as observers, an opportunity for immersive learning in this role is largely lost. If faculty value, the role of observer as critical for the learning potential associated then this role may be fully realized. 21 This study aimed to explore and describe peer observer and active participant thinking during simulation, to better understand shared learning experiences. Analysis of written responses to the question: 'What were you thinking' during a simulation-based experience (SBE) aimed to provide insight and increased clarity of student thinking, and to inform faculty and students about the impact of holistic nursing simulation. Examination of the impact of vicarious and active learning on student learning in this study was underpinned by social constructivism 22 and Kolb’s experiential learning framework, 23 which emphasizes the importance of social connectedness in learning interactions. Kolb’s work encourages learners to link their ‘new’ knowledge and experience to existing, thereby assisting them to broaden world views and challenge assumptions. 23 In this way experiential learning assists learners in making sense of their learning and integrating their knowledge in a wide variety of contexts. The guiding theory of social constructivism and framework of experiential learning were the lenses that researchers used to guide the research process. METHODS This study used a qualitative descriptive design to capture and explore nursing students’ thinking whilst in the role of simulation peer observer and active participant, after having engaged in a simulation-based experience (SBE ). An open-ended question was posed to all nursing students post SBE via an online survey. The study was conducted following the O’Briens’ et al standards for reporting qualitative research. 24 Setting and sample The setting for the study was an Australian university with a large Bachelor of Nursing second-year nursing clinical subject, comprised of preparatory theoretical content for laboratories and clinical placement. Students attended one 2-hour facilitated simulation which focused on a deteriorating patient scenario. A convenience sample of students enrolled in the second-year clinical subject (n = 1000) were eligible for inclusion in the study, there were no exclusion criteria. SBE facilitators delivered pre-brief to orientate students to the simulation objectives and role of participant and observer. Debriefing of both participants and observers immediately followed the simulation. Data collection Qualitative data was generated via peer observers and active participants’ self-reported experiences after participating in an SBE. Demographic information collected from participants included age, gender, enrolment status (part-time/full-time), the number of previous simulation sessions attended, course enrolment (degree, accelerated entry), and if previous tertiary study had been undertaken before the current course enrolment. All participants were asked to indicate if they were an observer or active participant. Participants were surveyed post-simulation using Key Survey, a web-based survey platform that asked an open-ended question depending on their role as either observer / active participant: ‘ What were some of the thoughts going through your mind when you were observing others’ practice? ’ or ‘ What were some of the thoughts going through your mind when you were actively participating in the simulation?’ Procedure After ethical approval, potential participants were advised of the study through electronic announcements and emails distributed through the university’s learning management system. At the university where this study was undertaken, a simulated learning experience was a standard element of their enrolled subject. Students self-allocated to a simulation group according to their availability. Class size was capped at eight students per simulation class and there were 129 simulation sessions in total. On the day of their scheduled simulation class, a research assistant invited students to participate in the study. Participant Information Sheets were provided and informed the participant of the study aim, procedure, and associated risks. Participants could opt out of the study at any time without penalty. At the commencement of the simulation class, students self-selected to be an active ‘participant’ (4 students) in the simulation or a ‘peer observer’ (4 students). The simulation facilitator delivered an orientation to the simulation room and a pre-brief which included addressing three broad domains of learning – communication: patient assessment and teamwork (10 minutes). The students who were active participants then participated in a 20-minute clinical scenario using 3G SimMan™. The participants who were peer observers sat in an observation room and completed an observation form . After the debriefing, participants were asked to complete a web-based survey, accessed via a QR Code or survey link. Completion of the survey indicated informed consent. Data analysis Peer observers' and active participants’ accounts of thinking were synthesized and analyzed using word cloud depiction and reflexive thematic analysis. Word clouds were generated using the web-based software WordClouds 25 to provide a visual source of analysis. Through the size of word depiction, word clouds highlighted the most frequent (largest) concepts in participant’s accounts. Two experienced researchers (initials removed for review) manually reviewed, loaded and reloaded data to remove repeated and redundant words, like pronouns and conjunctions. Peer observer and active participants' responses were synthesized and analyzed using reflexive thematic analysis. Initial codes were generated, and these were questioned and reviewed by the researchers independently and then together, to ensure no assumptions were applied and the focus was on keeping true to the research aim. 26 Similar codes were color-coded, collated and refined to generate themes, reflective of our interpretation of stories about the data under investigation. 26 Our process was collaborative and reflexive, staying true to the data and relationships, and holding true to our theoretical understandings underpinning this research. 27 FINDINGS Most of the participants were female (78%), between 21–30 years (53.8%), and enrolled full-time in the undergraduate Bachelor of Nursing program (97.1%). Of the four entry options to the BN program, the majority were Baccalaureate (previous degree) (35.8%) who had one previous simulation experience (49.2%) (Table 1 ). There were one hundred and seventy-five (n = 175) peer observer accounts and n = 234 active participant accounts analyzed. Table 1 Participant characteristics Characteristics Number Percentage Age, mean, SD 25.6 (6.8) Age groups < 20 years 107 25.9% 21–30 years 222 53.8% 31 and above 77 18.6% Missing 7 1.7% Gender Male 87 21.1% Female 322 78% Not specify 4 0.7% Enrolment Full time 401 97.1% Part time 12 2.9% Previous simulation sessions 0 160 38.7% 1 203 49.2% More than 1 (from 2–20) 42 10.1% Missing 8 1.9% Course enrolment Three-year degree 118 28.6% Baccalaureate (prior degree) 148 35.8% Diploma entry (prior diploma) 81 19.6% Double degree nursing/other discipline 56 13.6% Missing 10 2.4% Previous tertiary study before this course No, first experience 155 37.5% Yes, vocational study 97 23.5% Yes, other university study 158 38.3% Missing 3 0.7% Observer or not Yes 175 42.4% No 234 56.7% Missing 4 1.0% A word cloud generated from peer observer thinking accounts highlights patient focus; communication between active participants and the patient; and situational thinking, including patient assessment by the active participants. Peer observers’ observation of active participants seemed to elicit an emotional response including stress and nervousness. Peer observers related to the perceived performance and internal pressure experienced by the active participant and their thinking included reflective critique of self, as if they were in the role of active participant (Fig. 1 ). Peer observer thinking analytical interpretations (themes) From the 175 peer observer accounts, four codes were generated from analysis, these were synthesised by researchers (initials removed for review) into three themes (our analytical interpretations), including frequencies: Observer self-critique and critique of others; observer empathy and affect and observers’ outsider perspective (Table 2 and Fig. 2 ). Participant's accounts may have fallen into more than one area of data analysis. Table 2 Codes, theme, and frequency of Peer Observer thinking organized by analytical interpretation Code : Critique of self and peers n = 104 Theme : Observer self-critique and critique of active participant Codes : Being empathetic n = 39 and Emotional response n = 35 Theme : Observer empathy and affect Code : Distance from the simulation n = 26 Theme : Observers’ outsider perspective Observer self-critique and critique of others (active participant) Observer self-critique and critique of others was the dominant theme from the observer perspective (n = 104), with variation in critique from descriptive #51 The [participant] students did very well” to higher level evaluation #176 “ We had an excellent team leader who guided the simulation. They were aware of what needed to be done regarding patient assessments. Their assessments could have been more thorough and precise however. Minimal observer comments (10.6% or n = 11) included both self and critique of an active participant. Participant #78 best describes this dual observer role as both self and other critique when they commented I considered what I would've done differently but also recognized that within the moment with the intensity and subconscious stress placed upon the students, I likely would've responded similarly. I also could recognize how easily students can forget fundamental skills when under pressure. Observer empathy and affect Peer observer empathy and affect demonstrated that an emotional response was elicited by observers watching active peers participating in the simulation. #97 It was frantic and I was glad I wasn’t a participant. Everyone was obviously nervous and didn’t know one another. An emotional connection with the active participants was evident with empathetic accounts given by observers, highlighting a willingness to vicariously connect themselves to their peers and provide them with support. #112 That I wanted to help the participants. They were stressed which made me feel stressed. I was also trying to put myself in their roles and wonder if I would be able to handle the stress better or not. Not only did observers articulate an emotional connection with the active participants, but they desired to assume the role, whilst watching to improve how they could cognitively engage with the scenario. Participant #123 wanted to …put myself as a participant, thinking what should I do if I dealt [sic] with this patient. Observers’ outsider perspective The ‘ observer as an outsider’ perspective typically identified observation as an easier role to assume in the simulation experience, with a perception of ‘distance’ between observer and active participant enabling a clearer view of what behaviors were required, completed, or omitted. #8 It was a lot easier seeing the simulation from an outsider’s perspective. All observers commented on things they did do, didn’t do and should have done and participant #108 stated It was easier to see from a distance some of the key things the participants were missing. Despite categorisation of accounts into three themes, participant accounts also indicated observer capacity to simultaneously be objectively critical of self and their peers, yet emotionally and empathetically connected. Active participants thinking analytical interpretations (themes) Word clouds were generated from active participants' accounts. ‘Patient’ was the most frequent word expressed by active participants and was also the highest frequency word expressed by peer observers. The word ‘nervous’ features prominently. Participating in the simulation elicited emotional accounts: panic’, ‘stress’ and ‘overwhelming’, and centered around ‘doing’ and ‘trying’ for both individual performance and teamwork to deliver patient care (Fig. 3 ). From the 234 active participant accounts, six codes were generated from analysis, these were reviewed, refined, and synthesized by researchers (initials removed for review) into three themes, our analytical interpretations: participant affect; participant cognition and participant confidence (Table 3 and Fig. 4 ). Table 3 Codes, themes and frequency of active participant thoughts organised by analytical interpretation Code : Emotion (n = 98) Theme : Participant Affect Codes : Applying theory to practice n = 50; blank mind n = 11 and time n = 11 Theme : Participant Cognition Codes : Self-doubt n = 20 and self-improvement, self-critique n = 42 Theme : Participant Confidence Participant affect Participant affect was the dominant theme generated. Participant affect encompassed a continuum of emotion from panic (negative) to excitement (emerging positive), including in the words of one participant #72 “pure terror’ , although the predominant cluster of emotions were panic, stress, nervousness and feeling overwhelmed. When excitement was mentioned, it was less frequent and usually in the context of an initial feeling of nervousness or combined nervousness with excitement. Participant cognition Participant cognition likewise was interpreted as a continuum of conscious thought from an empty mind to clear, intentional thoughts about how to apply what was learnt in class to the simulation scenario, as the patient was deteriorating. Participant #89 captures the thrust of altered cognition when engaged in simulation with this statement, When the emergency came out, the knowledge and theories that I have learned could not be performed. Instead, my mind just went blank. When participants mentioned time, it featured as a block to thinking and meant there was insufficient time to respond to the simulation scenario as experienced by active participant #192’... It all happened so quickly and it's not that I forgot what I had learnt but in feeling flustered just didn't take the time to properly process things. I also got distracted at points thinking about pathophysiology which was fun intellectually but slowed me down. Participant confidence Participant confidence ranged from self-doubt about the capacity to problem solve under simulation conditions, to self-critique whilst in an active state (thinking and doing). Some students suggested how they could improve their simulation experience based on being able to observe their active peers and their performance. Self-critique included critique of team performance from the perspective of the participant as well as the individuals’ performance. Active participant: the relationship between affect, confidence, and cognition About the active participant, there was a cross-over noted between two of the three themes- analytical interpretations (Fig. 5 ). These crossovers were between: Participant Affect and Participant confidence and Participant affect and Participant cognition. There was no noted cross-over of themes within the Peer Observers. The relationship between active participant affect and confidence was characterised by heightened negative emotion (panic and nervousness) and expressive self-doubt. Active participant # 269 conveyed stress and self-doubt, highlighting their uncertainty to continue with the simulation experience, even when simulation pre-learning had been completed. I felt very nervous and unsure of myself even having completed all pre-learning materials. Similarly, participant affect impacted on capacity to think clearly or even begin to process information arising from the simulation. As emotion intensified, within a grouping of nervousness, stress and panic, active participants recounted a tendency for what may be interpreted as harried thinking. Participant #121 identified the value of having previous real-life experience in an emergency, as a tool, to mitigate the impact of strong emotions on their thinking during the simulation. A lot of thoughts going through my mind during the simulation. I have the knowledge but it’s hard for me to apply it due to mixed feelings of anxiousness and nervousness. Overall, I learned a lot from this simulation. Helped me to have a little bit of background in a real-life emergency situation . Only two of the active participants (0.9%) relayed strategic thinking during simulation. These participants were intentional in applying theory to practice yet also had emotional accounts like others. One of the two participants, #233 , articulated an initial emotional response, followed by a conscious cognitive action - ‘I talked to myself’ and then they focused thinking on applying what was learnt from the Clinical Practice Sessions (CPS) (clinical skill laboratories). Firstly, I felt nervous then I talked to myself: and then conducted what I learned from CPS class. Active participant #233 acknowledged their emotion early when engaged in a potentially challenging learning activity and then consciously focused their thinking on the target area of learning to be acquired. Calling on previous understandings combined with emotional awareness seemed to facilitate application. The only other combined response of participant affect and cognition (applying theory to practice) was by participant # 234 I was nervous but excited. During the simulation many assessments came to my mind to perform on the patient, and I did not know where to start, but our group had good communication so we worked it [sic] out. Successful simulation learning for this participant was moderated by emotional accounts and quality emotional processing, brokered by the team members. Conversely, only 20.5% of active participants reported their thinking focused solely on the application of theory to practice with no emotional component. Combined analysis of peer observer and active participant thinking Affective accounts about simulation were a shared experience regardless of the role occupied by second-year nursing students during simulation. Whilst the active participant was experiencing a continuum of emotion from nervousness to panic, the observer was vicariously experiencing a similar emotional/stress continuum, with the addition of empathy for the active participant (Fig. 6 ). Empathy for patients is well-recognized as a key attribute of nursing practice and person-centred care (Levett-Jones et al., 2019). Critique of self was jointly experienced by peer observers and active participants, suggesting simulation is an effective tool for reflective practice which can be promoted within debriefing. DISCUSSION The emotional response elicited by simulation experience is well documented, especially about patient care. 28 This study used a simulation case with a deteriorating patient case scenario so emotive responses were expected. Two interesting results arose from this study: 1) observers empathizing with their peers (active participants) with experienced emotion (empathy) driving learning and 2) a shared mindset and parallel feelings of peer observers and active participants. Peer observers’ emotional and cognitive accounts for, and about the active participants, indicate that SBE can elicit empathy between peers. The significance of an overlap between vicarious and active participation in simulated learning, particularly in the peer observer role, prompts possible re-evaluation of current debriefing practices. Currently, the two roles are considered as discrete experiences and are reported as such in the literature, with standards for simulation design omitting the observer role. 29 This research confirms the value of including peer observers in the simulation experience, 5 but recommends educators extend the scope of debriefing to include explicit identification of empathetic accounts from observers, and add this to the simulation learning outcomes, and more broadly to development of therapeutic, person-centred and professional relationships. Our study has captured peer observer thinking as astute yet also aligning with a range of emotional accounts of the active participant. The value of the observer as an empathetic, evaluator of simulation is a desirable professional attribute. 10 Educators cannot underestimate the value of students experiencing empathy for patient groups in a learning situation, particularly in a relatively controlled experience of simulation. 30 , 28 Debriefing has evolved to recognise emotional processing and empathy for others within the simulation allowing time at the commencement of debriefing for this to take place. 13 Under-represented within the current simulation and debriefing approaches is the experience of empathy, by and for peers and the related learning that occurs because of strong emotions such as empathy. The researchers recommend that subject learning outcomes tacitly include empathy experienced by, and for students, as an outcome of simulation-based experiences. This study has shown how simulation, inclusive of both active and peer observer participants allows students to feel and practice empathy for each other, contributing to learning in the SBE. Educators can acknowledge empathy, whether it spontaneously occurs when peer feedback is provided or is facilitator prompted. In this way students in simulation are connecting in a community of practice through their experience of shared empathy. This significant finding supports explicit teaching of this ‘soft skill’ which is critical for the effective delivery of person-centered care 30 along with teamwork between peers. Simulation, inclusive of peer observers can build the capacity to transfer empathetic interactions during clinical care by undergraduate students. Debriefing needs to occupy a central role in building this shared connection between observer and participant, reflecting on how it feels to be empathetic and what reaction it elicits (behavioral). Empathy is not universally intuitive and explicit teaching and modelling, as for reflection, needs to occur. 31 , 32 Similarly learning from strong emotions may be prompted. Ongoing research is required to better understand how empathy-based care can be optimized in simulation as a legitimate mode of learning. Students readily identified with their peers when learning was challenging. Simple clinical intention, skill and actions were forgotten when pressure was present. Nuances of the peer observer role require attention to improve vicarious learning and post-simulation quality reflection. The intense emotions and stress response experienced when observing your peers can limit cognitive processing. The authors recommend adjusting debriefing practice to include emotional processing at the commencement of debriefing, for peer observers along with active participants. Learning within cognitive processing post-simulation has been shown to improve when the emotional response to the simulation experience has been elicited, acknowledged and processed. 13 A cognitive load has been demonstrated by both peer observers and active participants, which can limit deeper and sustained learning. Whilst this is not a new finding, it suggests that in simulation contexts underestimation of the intensity of immersion continues. The importance of empathy-based learning within a simulation experience can expand the application of simulation as a pedagogy in preparing nursing students for person-centered and holistic care. The opportunity to experience ‘empathic humility’ is shared within a tribe (sic) of nursing students 33 immersed in simulation. Limitation of Study Qualitative data of peer observer and active participant's thinking was a snapshot from a moment in time, post-simulation completion. Data collected at one time point, is limited in establishing relationships or cause and effect. This study was conducted at a single institution which may limit generalizability. Participant translation of thinking to practice was not captured for analysis. Peer-to-peer empathy and the role empathy played in cognitive processing were the main findings of this study and although the authors pose that this is a transferable skill, this was not explored, limiting inference to application to clinical practice. CONCLUSION In summary, the analysis of peer observer and active participant thoughts and reactions captured in this study provided unique insights into students’ experiences of delivering therapeutic care within a simulated environment. In planning simulation experiences faculty should activate the observer role as an opportunity for prioritizing the art (empathy) and science (cognitive processing of best practice) of holistic nursing care. In this way, the observer role and associated activities are scaffolded to promote active learning over sustaining a passive approach which can limit dynamic interpersonal interactions. Such approaches will maximize exposure to critical elements of holistic nursing, such as empathy-informed care. This study has highlighted how those in the peer observer role can experience simulation as an immersive and emotive experience that may indicate active and deep learning is occurring. As faculty, we can improve nursing students' capacity to apply empathy in practice by creating simulations that harness/target the experience of empathy (art) alongside the science of therapeutic care (cognition processing). Additionally, if such experiences mirror the learning active participants achieve and if this enables later transfer of learning to real care contexts, it is an area for future investigation. Declarations Ethical Approval and consent to participate: This study was reviewed and approved by Queensland University of Technology (QUT) Human Research Ethics Committee, with the approval number: 1400000499. Participants consented to study participation with completion of the survey. The study was conducted in accordance with the QUT Code for Responsible Conduct of Research https://mopp.qut.edu.au/document/view.php?id=154 which complies with the Australian Code for the Responsible Conduct of Research 2018 https://www.nhmrc.gov.au/about-us/publications/australian-code-responsible-conduct-research-2018 Consent for Publication: No individual identifiable data has been included in this manuscript. Availability of data and materials : The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Conflict of interest: Nil Funding : This study was funded by a Sigma Theta Tau Nurse Education Grant; however, the authors agree this funding did not influence the study process or outcomes. Credit Author Statement: Naomi Tutticci: Conceptualization, Methodology, Formal Analysis, Investigation, Writing – Original Draft, Writing – Review & Editing, Funding acquisition. Sandra Johnston: Conceptualization, Methodology, Writing – Original Draft, Writing – Review & Editing. Joanne Ramsbotham: Conceptualization, Methodology, Writing – Original Draft, Writing – Review & Editing. Karen Theobald: Conceptualization, Methodology, Formal Analysis, Investigation, Writing – Original Draft, Writing – Review & Editing. Acknowledgements: Not applicable References Henry D. Rediscovering the art of nursing to enhance nursing practice. Nurs Sci Q. 2018;31(1):47–54. doi: 10.1177/0894318417741117 Koukourikos K, Tsaloglidou A, Kourkouta L, Papathanasiou IV, Iliadis C, Fratzana A, et al. 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Clin Simul Nurs. 2023;78:7–17. doi: 10.1016/j.ecns.2023.02.003 Rogers BA, Baker KA, Sapp A. Learning outcomes of the observer role in nursing simulation: a scoping review protocol. JBI Evid Synth. 2020;18(5):1051–6. doi: 10.11124/JBISRIR-D-19-00172 Byrne AL, Baldwin A, Harvey C. Whose centre is it anyway? Defining person-centred care in nursing: an integrative review. PLoS One. 2020;15(3):e0229923. doi: 10.1371/journal.pone.0229923 Berduzco-Torres N, Medina P, San-Martín M, Delgado Bolton RC, Vivanco L. Non-academic factors influencing empathy in nursing students: a cross-sectional study. BMC Nurs. 2021;20(1). doi: 10.1186/s12912-021-00773-2 Kwame A, Petrucka PM. A literature-based study of patient-centered care and communication in nurse-patient interactions: barriers, facilitators, and the way forward. BMC Nurs. 2021;20(1). doi: 10.1186/s12912-021-00684-2 Lioce L, Lopreiato J, Downing D, Chang TP, Robertson JM, Rogers BA, et al. 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Nurse Educ Pract. 2017;24:6–13. doi: 10.1016/j.nepr.2017.03.001 Bonnel W, Hober C. Optimizing the reflective observer role in high-fidelity patient simulation. J Nurs Educ. 2016;55(6):353–6. doi: 10.3928/01484834-20160516-10 Livsey K, Lavender-Stott E. Impact of vicarious learning through peer observation during simulation on student behavioural measures. Focus Health Prof Educ. 2015;16(4):64–73. doi: 10.11157/fohpe.v16i4.99 Shin AR, Roh YS. Efficacy of observational learning on nursing students’ learning outcomes in delirium care simulation: a parallel-group randomized trial. Nurse Educ Today. 2025;147:106574. doi: 10.1016/j.nedt.2025.106574 Clark SB, Lippe MP. Vicarious learning and communication self-efficacy: a pediatric end-of-life simulation for pre-licensure nursing students. J Prof Nurs. 2022;43:107–16. doi: 10.1016/j.profnurs.2022.09.008 Brooks J, Brooks MG. In search of understanding: the case for constructivist classrooms. 2nd ed. Alexandria, VA: Association for Supervision and Curriculum Development; 1999. Kolb DA. Experiential learning: experience as the source of learning and development. Englewood Cliffs, NJ: Prentice-Hall; 1984. O’Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative research: a synthesis of recommendations. Acad Med. 2014;89(9):1245–51. doi: 10.1097/ACM.0000000000000388 WordClouds. WordClouds.com [Internet]. [cited 2025 Jul 4]. Available from: https://www.wordclouds.com/ Braun V, Clarke V. Reflecting on reflexive thematic analysis. Qual Res Sport Exerc Health. 2019;11(4):589–97. doi: 10.1080/2159676X.2019.1628806 Rapley T. Some pragmatics of qualitative data analysis. In: Silverman D, editor. Qualitative research. 4th ed. London: Sage Publications Ltd; 2016. Witherspoon M, Pankonien CA, Baldwin J, Hunter C. The impact of a role-play patient simulation on nursing students as measured by the comprehensive state empathy scale. Teach Learn Nurs. 2023;18(3):e79–83. Watts PI, McDermott DS, Alinier G, Charnetski M, Ludlow J, Horsley E, et al. Healthcare simulation standards of best practice™: simulation design. Clin Sim Nurs. 2021;58:14–21. doi: 10.1016/j.ecns.2021.08.009 Levett-Jones T, Cant R, Lapkin S. A systematic review of the effectiveness of empathy education for undergraduate nursing students. Nurse Educ Today. 2019;75:80–4. doi: 10.1016/j.nedt.2019.01.006 Juniarta ENGA, Sitanggang YF. Empathy in nursing students: a scoping review. J Holist Nurs. 2024;42(2S):S59–86. doi: 10.1177/08980101231163966 Li J, Li X, Gu L, Zhang R, Zhao R, Cai Q, et al. Effects of simulation-based deliberate practice on nursing students’ communication, empathy, and self-efficacy. J Nurs Educ. 2019;58(12):681–9. doi: 10.3928/01484834-20191120-02 Levett-Jones T, Cant R. The empathy continuum: an evidenced-based teaching model derived from an integrative review of contemporary nursing literature. J Clin Nurs. 2020;29(7–8):1026–40. doi: 10.1111/jocn.15137 Additional Declarations No competing interests reported. Supplementary Files SupplementaryFile.docx Cite Share Download PDF Status: Published Journal Publication published 02 Dec, 2025 Read the published version in Advances in Simulation → Version 1 posted Editorial decision: Revision requested 05 Sep, 2025 Reviews received at journal 03 Sep, 2025 Reviews received at journal 24 Aug, 2025 Reviewers agreed at journal 14 Aug, 2025 Reviewers agreed at journal 05 Aug, 2025 Reviewers invited by journal 05 Aug, 2025 Editor assigned by journal 21 Jul, 2025 Submission checks completed at journal 21 Jul, 2025 First submitted to journal 03 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7042715","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":496266980,"identity":"7b90cef0-6b87-42c7-a4c3-433ac46bcbe6","order_by":0,"name":"Naomi Tutticci","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBUlEQVRIie3RMUvDQBTA8RcO3nTtrVeE3Fd4IVBb9MPcpIuDU+lUUoS6VFzzSTqfHNgldO7YIri4tLh0qOA7Sh0k2oyC94eER3g/LiEAsdjfTQMI4QAoVQiSH+Bv2wLA2UDQMsk7E2xGwiCJb3mnOEXOQT2fbXc9o+7l+9vwlnTbPDjYDDyo0taSfiFQ84tlpW/N+hWRRmzbpFx40Mt6Qu5ALInWLCtoP0KUPE88wGkiX5mEU5h8MDENiFh/kYQJ/US8yHvVVfgW7CYHckNP08W1zKpVPZmP18vh5cioR/+yLfakzV2VrXaDizSd158Sfssx1MfJ8SXr97/pTZOtWCwW+399AvUEUMDddlJtAAAAAElFTkSuQmCC","orcid":"","institution":"Griffith University","correspondingAuthor":true,"prefix":"","firstName":"Naomi","middleName":"","lastName":"Tutticci","suffix":""},{"id":496266981,"identity":"3e9e187e-f87d-43d9-bd83-5653bf6eabcc","order_by":1,"name":"Sandra Johnston","email":"","orcid":"","institution":"Queensland University of Technology","correspondingAuthor":false,"prefix":"","firstName":"Sandra","middleName":"","lastName":"Johnston","suffix":""},{"id":496266982,"identity":"79b30281-063d-4390-9da5-6c5119494977","order_by":2,"name":"Joanne Ramsbotham","email":"","orcid":"","institution":"Queensland University of Technology","correspondingAuthor":false,"prefix":"","firstName":"Joanne","middleName":"","lastName":"Ramsbotham","suffix":""},{"id":496266983,"identity":"00c20558-8bf6-47d2-a4e2-2b8fd2eed8da","order_by":3,"name":"Karen Theobald","email":"","orcid":"","institution":"Queensland University of Technology","correspondingAuthor":false,"prefix":"","firstName":"Karen","middleName":"","lastName":"Theobald","suffix":""}],"badges":[],"createdAt":"2025-07-04 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10:04:37","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":33430,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAn example of the data analysis process for peer observers\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7042715/v1/e3a2253db011d4939be63045.png"},{"id":88775097,"identity":"19687d03-8408-449f-a2cf-cb1e4ac1ccb2","added_by":"auto","created_at":"2025-08-11 10:04:37","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":283310,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eActive participant thinking word cloud\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7042715/v1/6e408fb1b688cbc9a17727c8.png"},{"id":88775096,"identity":"4a0fda5a-3e0f-4825-8457-b5e365a8832b","added_by":"auto","created_at":"2025-08-11 10:04:37","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":30824,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAn example of the data analysis process for active participants\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-7042715/v1/f0ae78d5dff2ecb1f3a44c5d.png"},{"id":88775095,"identity":"31cde317-90aa-4363-b4ad-00750396de5c","added_by":"auto","created_at":"2025-08-11 10:04:37","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":13484,"visible":true,"origin":"","legend":"\u003cp\u003eVenn diagram showing inter-relationships between participant affect, cognition and confidence\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-7042715/v1/6f1ea0ade85294519b2b7f11.png"},{"id":88777462,"identity":"c8a90930-d49d-48ed-b5b4-8643af587f36","added_by":"auto","created_at":"2025-08-11 10:12:37","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":28796,"visible":true,"origin":"","legend":"\u003cp\u003eShared affective experiences (Peer Observer and Participant)\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-7042715/v1/e01cecf9ec3d3b121b2ef29c.png"},{"id":97723780,"identity":"c1afdfd6-cebd-413f-bad5-bb9d557b7186","added_by":"auto","created_at":"2025-12-08 16:06:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1349462,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7042715/v1/0e596aad-4073-4b5c-b1a2-56f2ddc4d0bf.pdf"},{"id":88778051,"identity":"a58c2414-b9de-4a19-9a12-9d19dc62a931","added_by":"auto","created_at":"2025-08-11 10:20:37","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":56603,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFile.docx","url":"https://assets-eu.researchsquare.com/files/rs-7042715/v1/53daeb5d28ecf409b919a74f.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"An Immersive Mirror: A Descriptive Study of Peer Observer and Active Participant Experiences in Simulation","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eMany nursing students have limited experience caring for, and an understanding of patients lived experiences. As faculty, we need to be mindful of purposefully balancing learning in the intuitive art, scientific knowledge, and technical capability domains of nursing when preparing undergraduate nursing students.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Simulation provides a safe, reality-based and interactive environment for students to practice their abilities, make mistakes and repeat the process leading to mastery.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e This provides an opportunity for students\u0026rsquo; active participation and direct monitoring by their peers, improving their understanding of care provision because it is seen and applied.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Holistic nursing simulation combines simulation pedagogy with holistic nursing philosophy promoting students\u0026rsquo; self-awareness and a grasp of others\u0026rsquo; perspectives in a caring and healing relationship.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eThe active participant experience in simulation has been extensively evaluated and is largely understood with recent refinements to simulation design evolving as experiential learning for both participant and observer is prioritized. The active participant and observer simulation model is commonly used, allowing participants to immerse themselves safely, in real-world clinical scenarios.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e In this simulation model, observers typically provide feedback during debriefing with facilitator guidance.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e To date, simulation design and implementation have focused on optimizing this real-world, simulated experience. This is not disputed as being of value as it is essential for improving the student learning experience. Little is known however about peer observer thoughts during simulation and further how an understanding of this phenomenon may translate to improvements in simulation design and implementation.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Peer observers learn vicariously in simulation-based experiences (SBE) but also may experience similar thoughts and reactions to active participants. This paper argues that peer observers could experience both vicarious and immersive learning, a position not universally evident in contemporary literature.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e Similar thoughts and reactions by both peer observers and active participants suggest an emerging simulation phenomenon, worthy of further exploration if such an approach optimizes understanding of each other as whole beings.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e"},{"header":"BACKGROUND","content":"\u003cp\u003eSimulation is highly valued by educators as a pedagogy to safely and effectively prepare nursing students for practice. The experiential nature of simulation allows students to test their understanding of person-centered, holistic care in the context of the scope of practice, skill acquisition, teamwork, and communication.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Within such immersive experiences, soft or interpersonal skills are the cornerstone of person-centered care,\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e often evident in effective communication that requires the nurse / student to understand what it means to be human: capable of expressing warmth and respect, treating patients and caregivers with dignity and compassion, genuineness, and empathy.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e Experiencing these aspects of humanness, within an immersive, yet safe and controlled simulation can better equip nursing students to deliver sensitive and holistic care.\u003c/p\u003e\u003cp\u003eFull immersion in simulation is characterized by the participant\u0026rsquo;s deep and holistic involvement of senses, emotions, thinking and behavior. Immersion describes the level to which the learner becomes involved in the simulation; a high degree of immersion indicates that the learner is treating the simulation as if it were a real-life (or very close to real-life) event.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e Deep immersion is more likely when the fidelity of the simulation closely aligns with reality (emotional, conceptual and physical) as well as the participant\u0026acute;s perception of realism.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eStudent engagement in simulation is enabled by peer presence with contribution and expertise from experienced facilitators. Barriers to engagement in simulation have been reported as arising from student anticipatory anxiety, poor preparation, and lack of skilled facilitation.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e Simulation can incorporate both an \u0026lsquo;active participant\u0026rsquo; and \u0026lsquo;peer observer role\u0026rsquo;, the active participant is required to immerse themselves in an allocated role, in the simulation scenario, whilst the observer is typically physically distanced from the scenario, whilst documenting observations via a worksheet or cognitive aid that focusses attention and scaffolds thinking.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e While the participant experience of simulation has been well documented, what is less understood is peer observer reactions during simulation.\u003c/p\u003e\u003cp\u003eObservation of simulation aligns with vicarious learning principles. Vicarious and immersive learning have appeal for the adult learner, with benefits attributed to both forms of learning.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e Vicarious learning or learning from the behavior of others is a concept derived from the work of Bandura.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e Watching your peers in the simulation observer role can provoke learning through an alternate mode and reduce the cognitive load associated with immersive learning, particularly when new skills are being acquired.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e Numerous advantages are associated with the peer observer role, including learning from an objective position, opportunities for reflective practice and increasing student participation in the experience.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e Conversely, observation as learning is not considered to be a true form of experiential learning as active participation is required.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e Conceptually, vicarious learning via observation of peers during simulation has been posed as more valuable than active participation especially when combined with evaluative peer feedback.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e Learning through the observation of others is a known concept but it has not been investigated thoroughly as an aspect of experiential learning in simulation contexts.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eUnderstanding how quality SBE learning outcomes are obtained is obscured when the peer observer role is poorly reported and studies rarely distinguish between active participant and observer\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e as this limits a deeper conceptual understanding of the shared functionality of the roles and the distinct differences. To optimize learning when physically separated whilst maintaining an intellectual connection with the scenario, a structured approach to peer observation is often used, such as a worksheet.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e The authors postulate that if peer observers are given little direction on their role or are not provided with a tool that directs their action as observers, an opportunity for immersive learning in this role is largely lost. If faculty value, the role of observer as critical for the learning potential associated then this role may be fully realized.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eThis study aimed to explore and describe peer observer and active participant thinking during simulation, to better understand shared learning experiences. Analysis of written responses to the question: 'What were you thinking' during a simulation-based experience (SBE) aimed to provide insight and increased clarity of student thinking, and to inform faculty and students about the impact of holistic nursing simulation.\u003c/p\u003e\u003cp\u003eExamination of the impact of vicarious and active learning on student learning in this study was underpinned by social constructivism\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e and Kolb\u0026rsquo;s experiential learning framework,\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e which emphasizes the importance of social connectedness in learning interactions. Kolb\u0026rsquo;s work encourages learners to link their \u0026lsquo;new\u0026rsquo; knowledge and experience to existing, thereby assisting them to broaden world views and challenge assumptions.\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e In this way experiential learning assists learners in making sense of their learning and integrating their knowledge in a wide variety of contexts. The guiding theory of social constructivism and framework of experiential learning were the lenses that researchers used to guide the research process.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eThis study used a qualitative descriptive design to capture and explore nursing students\u0026rsquo; thinking whilst in the role of simulation peer observer and active participant, after having engaged in a simulation-based experience \u003cem\u003e(SBE\u003c/em\u003e). An open-ended question was posed to all nursing students post SBE via an online survey. The study was conducted following the O\u0026rsquo;Briens\u0026rsquo; et al standards for reporting qualitative research.\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eSetting and sample\u003c/span\u003e\u003c/p\u003e\u003cp\u003eThe setting for the study was an Australian university with a large Bachelor of Nursing second-year nursing clinical subject, comprised of preparatory theoretical content for laboratories and clinical placement. Students attended one 2-hour facilitated simulation which focused on a deteriorating patient scenario. A convenience sample of students enrolled in the second-year clinical subject (n\u0026thinsp;=\u0026thinsp;1000) were eligible for inclusion in the study, there were no exclusion criteria. SBE facilitators delivered pre-brief to orientate students to the simulation objectives and role of participant and observer. Debriefing of both participants and observers immediately followed the simulation.\u003c/p\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eData collection\u003c/span\u003e\u003c/p\u003e\u003cp\u003eQualitative data was generated via peer observers and active participants\u0026rsquo; self-reported experiences after participating in an SBE. Demographic information collected from participants included age, gender, enrolment status (part-time/full-time), the number of previous simulation sessions attended, course enrolment (degree, accelerated entry), and if previous tertiary study had been undertaken before the current course enrolment. All participants were asked to indicate if they were an observer or active participant.\u003c/p\u003e\u003cp\u003eParticipants were surveyed post-simulation using Key Survey, a web-based survey platform that asked an open-ended question depending on their role as either observer / active participant: \u0026lsquo;\u003cem\u003eWhat were some of the thoughts going through your mind when you were observing others\u0026rsquo; practice?\u003c/em\u003e\u0026rsquo; or \u0026lsquo;\u003cem\u003eWhat were some of the thoughts going through your mind when you were actively participating in the simulation?\u0026rsquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eProcedure\u003c/span\u003e\u003c/p\u003e\u003cp\u003eAfter ethical approval, potential participants were advised of the study through electronic announcements and emails distributed through the university\u0026rsquo;s learning management system. At the university where this study was undertaken, a simulated learning experience was a standard element of their enrolled subject. Students self-allocated to a simulation group according to their availability. Class size was capped at eight students per simulation class and there were 129 simulation sessions in total.\u003c/p\u003e\u003cp\u003eOn the day of their scheduled simulation class, a research assistant invited students to participate in the study. Participant Information Sheets were provided and informed the participant of the study aim, procedure, and associated risks. Participants could opt out of the study at any time without penalty. At the commencement of the simulation class, students self-selected to be an active \u0026lsquo;participant\u0026rsquo; (4 students) in the simulation or a \u0026lsquo;peer observer\u0026rsquo; (4 students). The simulation facilitator delivered an orientation to the simulation room and a pre-brief which included addressing three broad domains of learning \u0026ndash; communication: patient assessment and teamwork (10 minutes). The students who were active participants then participated in a 20-minute clinical scenario using 3G SimMan\u0026trade;. The participants who were peer observers sat in an observation room and completed an observation form\u0026thinsp;\u0026lt;\u0026thinsp;Supplementary File\u0026gt;. After the debriefing, participants were asked to complete a web-based survey, accessed via a QR Code or survey link. Completion of the survey indicated informed consent.\u003c/p\u003e\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e\u003ch2\u003eData analysis\u003c/h2\u003e\u003cp\u003e Peer observers' and active participants\u0026rsquo; accounts of thinking were synthesized and analyzed using word cloud depiction and reflexive thematic analysis. Word clouds were generated using the web-based software WordClouds\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e to provide a visual source of analysis. Through the size of word depiction, word clouds highlighted the most frequent (largest) concepts in participant\u0026rsquo;s accounts. Two experienced researchers (initials removed for review) manually reviewed, loaded and reloaded data to remove repeated and redundant words, like pronouns and conjunctions.\u003c/p\u003e\u003cp\u003e Peer observer and active participants' responses were synthesized and analyzed using reflexive thematic analysis. Initial codes were generated, and these were questioned and reviewed by the researchers independently and then together, to ensure no assumptions were applied and the focus was on keeping true to the research aim.\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e Similar codes were color-coded, collated and refined to generate themes, reflective of our interpretation of stories about the data under investigation.\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e Our process was collaborative and reflexive, staying true to the data and relationships, and holding true to our theoretical understandings underpinning this research.\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e"},{"header":"FINDINGS","content":"\u003cp\u003eMost of the participants were female (78%), between 21\u0026ndash;30 years (53.8%), and enrolled full-time in the undergraduate Bachelor of Nursing program (97.1%). Of the four entry options to the BN program, the majority were Baccalaureate (previous degree) (35.8%) who had one previous simulation experience (49.2%) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). There were one hundred and seventy-five (n\u0026thinsp;=\u0026thinsp;175) peer observer accounts and n\u0026thinsp;=\u0026thinsp;234 active participant accounts analyzed.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eParticipant characteristics\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNumber\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePercentage\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge, mean, SD\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e25.6 (6.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge groups\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;20 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e107\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25.9%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e21\u0026ndash;30 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e222\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e53.8%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e31 and above\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e77\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18.6%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMissing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.7%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e87\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21.1%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e322\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e78%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNot specify\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.7%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEnrolment\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFull time\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e401\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e97.1%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePart time\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.9%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrevious simulation sessions\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e160\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e38.7%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e203\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e49.2%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMore than 1 (from 2\u0026ndash;20)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10.1%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMissing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.9%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCourse enrolment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eThree-year degree\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e118\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e28.6%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBaccalaureate (prior degree)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e148\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e35.8%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDiploma entry (prior diploma)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e19.6%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDouble degree nursing/other discipline\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13.6%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMissing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.4%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrevious tertiary study before this course\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo, first experience\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e155\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e37.5%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes, vocational study\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e97\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e23.5%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes, other university study\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e158\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e38.3%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMissing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.7%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eObserver or not\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e175\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e42.4%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e234\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e56.7%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMissing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.0%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e A word cloud generated from peer observer thinking accounts highlights patient focus; communication between active participants and the patient; and situational thinking, including patient assessment by the active participants. Peer observers\u0026rsquo; observation of active participants seemed to elicit an emotional response including stress and nervousness. Peer observers related to the perceived performance and internal pressure experienced by the active participant and their thinking included reflective critique of self, as if they were in the role of active participant (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003ePeer observer thinking analytical interpretations (themes)\u003c/span\u003e\u003c/p\u003e\u003cp\u003eFrom the 175 peer observer accounts, four codes were generated from analysis, these were synthesised by researchers (initials removed for review) into three themes (our analytical interpretations), including frequencies: Observer self-critique and critique of others; observer empathy and affect and observers\u0026rsquo; outsider perspective (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Participant's accounts may have fallen into more than one area of data analysis.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCodes, theme, and frequency of Peer Observer thinking organized by analytical interpretation\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCode\u003c/b\u003e: Critique of self and peers n\u0026thinsp;=\u0026thinsp;104\u003c/p\u003e\u003cp\u003e\u003cb\u003eTheme\u003c/b\u003e: Observer self-critique and critique of active participant\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eCodes\u003c/b\u003e: Being empathetic n\u0026thinsp;=\u0026thinsp;39 and Emotional response n\u0026thinsp;=\u0026thinsp;35\u003c/p\u003e\u003cp\u003e\u003cb\u003eTheme\u003c/b\u003e: Observer empathy and affect\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eCode\u003c/b\u003e: Distance from the simulation n\u0026thinsp;=\u0026thinsp;26\u003c/p\u003e\u003cp\u003e\u003cb\u003eTheme\u003c/b\u003e: Observers\u0026rsquo; outsider perspective\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eObserver self-critique and critique of others (active participant)\u003c/span\u003e\u003c/p\u003e\u003cp\u003eObserver self-critique and critique of others was the dominant theme from the observer perspective (n\u0026thinsp;=\u0026thinsp;104), with variation in critique from descriptive #51 \u003cem\u003eThe [participant] students did very well\u0026rdquo;\u003c/em\u003e to higher level evaluation #176 \u0026ldquo;\u003cem\u003eWe had an excellent team leader who guided the simulation. They were aware of what needed to be done regarding patient assessments. Their assessments could have been more thorough and precise however.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e Minimal observer comments (10.6% or n\u0026thinsp;=\u0026thinsp;11) included both self and critique of an active participant. Participant \u003cem\u003e#78\u003c/em\u003e best describes this dual observer role as both self and other critique when they commented \u003cem\u003eI considered what I would've done differently but also recognized that within the moment with the intensity and subconscious stress placed upon the students, I likely would've responded similarly. I also could recognize how easily students can forget fundamental skills when under pressure.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eObserver empathy and affect\u003c/span\u003e\u003c/p\u003e\u003cp\u003ePeer observer empathy and affect demonstrated that an emotional response was elicited by observers watching active peers participating in the simulation.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e#97 \u003cem\u003eIt was frantic and I was glad I wasn\u0026rsquo;t a participant. Everyone was obviously nervous and didn\u0026rsquo;t know one another.\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e An emotional connection with the active participants was evident with empathetic accounts given by observers, highlighting a willingness to vicariously connect themselves to their peers and provide them with support.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e#112 That I wanted to help the participants. They were stressed which made me feel stressed. I was also trying to put myself in their roles and wonder if I would be able to handle the stress better or not.\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e Not only did observers articulate an emotional connection with the active participants, but they desired to assume the role, whilst watching to improve how they could cognitively engage with the scenario. Participant #123 wanted to \u003cem\u003e\u0026hellip;put myself as a participant, thinking what should I do if I dealt [sic] with this patient.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eObservers\u0026rsquo; outsider perspective\u003c/span\u003e\u003c/p\u003e\u003cp\u003eThe \u0026lsquo;\u003cem\u003eobserver as an outsider\u0026rsquo;\u003c/em\u003e perspective typically identified observation as an easier role to assume in the simulation experience, with a perception of \u0026lsquo;distance\u0026rsquo; between observer and active participant enabling a clearer view of what behaviors were required, completed, or omitted.\u003c/p\u003e\u003cp\u003e#8 \u003cem\u003eIt was a lot easier seeing the simulation from an outsider\u0026rsquo;s perspective. All observers commented on things they did do, didn\u0026rsquo;t do and should have done\u003c/em\u003e and participant #108 stated \u003cem\u003eIt was easier to see from a distance some of the key things the participants were missing.\u003c/em\u003e\u003c/p\u003e\u003cp\u003eDespite categorisation of accounts into three themes, participant accounts also indicated observer capacity to simultaneously be objectively critical of self and their peers, yet emotionally and empathetically connected.\u003c/p\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eActive participants thinking analytical interpretations (themes)\u003c/span\u003e\u003c/p\u003e\u003cp\u003e Word clouds were generated from active participants' accounts. \u0026lsquo;Patient\u0026rsquo; was the most frequent word expressed by active participants and was also the highest frequency word expressed by peer observers. The word \u0026lsquo;nervous\u0026rsquo; features prominently. Participating in the simulation elicited emotional accounts: panic\u0026rsquo;, \u0026lsquo;stress\u0026rsquo; and \u0026lsquo;overwhelming\u0026rsquo;, and centered around \u0026lsquo;doing\u0026rsquo; and \u0026lsquo;trying\u0026rsquo; for both individual performance and teamwork to deliver patient care (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eFrom the 234 active participant accounts, six codes were generated from analysis, these were reviewed, refined, and synthesized by researchers (initials removed for review) into three themes, our analytical interpretations: participant affect; participant cognition and participant confidence (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCodes, themes and frequency of active participant thoughts organised by analytical interpretation\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCode\u003c/b\u003e: Emotion (n\u0026thinsp;=\u0026thinsp;98)\u003c/p\u003e\u003cp\u003e\u003cb\u003eTheme\u003c/b\u003e: Participant Affect\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eCodes\u003c/b\u003e: Applying theory to practice n\u0026thinsp;=\u0026thinsp;50; blank mind n\u0026thinsp;=\u0026thinsp;11 and time n\u0026thinsp;=\u0026thinsp;11\u003c/p\u003e\u003cp\u003e\u003cb\u003eTheme\u003c/b\u003e: Participant Cognition\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eCodes\u003c/b\u003e: Self-doubt n\u0026thinsp;=\u0026thinsp;20 and self-improvement, self-critique n\u0026thinsp;=\u0026thinsp;42\u003c/p\u003e\u003cp\u003e\u003cb\u003eTheme\u003c/b\u003e: Participant Confidence\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eParticipant affect\u003c/span\u003e\u003c/p\u003e\u003cp\u003eParticipant affect was the dominant theme generated. Participant affect encompassed a continuum of emotion from panic (negative) to excitement (emerging positive), including in the words of one participant #72 \u003cem\u003e\u0026ldquo;pure terror\u0026rsquo;\u003c/em\u003e, although the predominant cluster of emotions were panic, stress, nervousness and feeling overwhelmed. When excitement was mentioned, it was less frequent and usually in the context of an initial feeling of nervousness or combined nervousness with excitement.\u003c/p\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eParticipant cognition\u003c/span\u003e\u003c/p\u003e\u003cp\u003eParticipant cognition likewise was interpreted as a continuum of conscious thought from an empty mind to clear, intentional thoughts about how to apply what was learnt in class to the simulation scenario, as the patient was deteriorating. Participant #89 captures the thrust of altered cognition when engaged in simulation with this statement, \u003cem\u003eWhen the emergency came out, the knowledge and theories that I have learned could not be performed. Instead, my mind just went blank.\u003c/em\u003e\u003c/p\u003e\u003cp\u003eWhen participants mentioned time, it featured as a block to thinking and meant there was insufficient time to respond to the simulation scenario as experienced by active participant #192\u0026rsquo;...\u003cem\u003eIt all happened so quickly and it's not that I forgot what I had learnt but in feeling flustered just didn't take the time to properly process things. I also got distracted at points thinking about pathophysiology which was fun intellectually but slowed me down.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eParticipant confidence\u003c/span\u003e\u003c/p\u003e\u003cp\u003eParticipant confidence ranged from self-doubt about the capacity to problem solve under simulation conditions, to self-critique whilst in an active state (thinking and doing). Some students suggested how they could improve their simulation experience based on being able to observe their active peers and their performance. Self-critique included critique of team performance from the perspective of the participant as well as the individuals\u0026rsquo; performance.\u003c/p\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eActive participant: the relationship between affect, confidence, and cognition\u003c/span\u003e\u003c/p\u003e\u003cp\u003eAbout the active participant, there was a cross-over noted between two of the three themes- analytical interpretations (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). These crossovers were between: Participant Affect and Participant confidence and Participant affect and Participant cognition. There was no noted cross-over of themes within the Peer Observers.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe relationship between active participant affect and confidence was characterised by heightened negative emotion (panic and nervousness) and expressive self-doubt. Active participant \u003cem\u003e# 269\u003c/em\u003e conveyed stress and self-doubt, highlighting their uncertainty to continue with the simulation experience, even when simulation pre-learning had been completed.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eI felt very nervous and unsure of myself even having completed all pre-learning materials.\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eSimilarly, participant affect impacted on capacity to think clearly or even begin to process information arising from the simulation. As emotion intensified, within a grouping of nervousness, stress and panic, active participants recounted a tendency for what may be interpreted as harried thinking. Participant #121 identified the value of having previous real-life experience in an emergency, as a tool, to mitigate the impact of strong emotions on their thinking during the simulation.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eA lot of thoughts going through my mind during the simulation. I have the knowledge but it\u0026rsquo;s hard for me to apply it due to mixed feelings of anxiousness and nervousness. Overall, I learned a lot from this simulation. Helped me to have a little bit of background in a real-life emergency situation\u003c/em\u003e.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eOnly two of the active participants (0.9%) relayed strategic thinking during simulation. These participants were intentional in applying theory to practice yet also had emotional accounts like others. One of the two participants, \u003cem\u003e#233\u003c/em\u003e, articulated an initial emotional response, followed by a conscious cognitive action - \u003cem\u003e\u0026lsquo;I talked to\u003c/em\u003e myself\u0026rsquo; and then they focused thinking on applying what was learnt from the Clinical Practice Sessions (CPS) (clinical skill laboratories).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eFirstly, I felt nervous then I talked to myself: and then conducted what I learned from CPS class.\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e Active participant #233 acknowledged their emotion early when engaged in a potentially challenging learning activity and then consciously focused their thinking on the target area of learning to be acquired. Calling on previous understandings combined with emotional awareness seemed to facilitate application. The only other combined response of participant affect and cognition (applying theory to practice) was by participant # 234\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eI was nervous but excited. During the simulation many assessments came to my mind to perform on the patient, and I did not know where to start, but our group had good communication so we worked it [sic] out.\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eSuccessful simulation learning for this participant was moderated by emotional accounts and quality emotional processing, brokered by the team members.\u003c/p\u003e\u003cp\u003eConversely, only 20.5% of active participants reported their thinking focused solely on the application of theory to practice with no emotional component.\u003c/p\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eCombined analysis of peer observer and active participant thinking\u003c/span\u003e\u003c/p\u003e\u003cp\u003eAffective accounts about simulation were a shared experience regardless of the role occupied by second-year nursing students during simulation. Whilst the active participant was experiencing a continuum of emotion from nervousness to panic, the observer was vicariously experiencing a similar emotional/stress continuum, with the addition of empathy for the active participant (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e). Empathy for patients is well-recognized as a key attribute of nursing practice and person-centred care (Levett-Jones et al., 2019). Critique of self was jointly experienced by peer observers and active participants, suggesting simulation is an effective tool for reflective practice which can be promoted within debriefing.\u003c/p\u003e\u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe emotional response elicited by simulation experience is well documented, especially about patient care.\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e This study used a simulation case with a deteriorating patient case scenario so emotive responses were expected. Two interesting results arose from this study: 1) observers empathizing with their peers (active participants) with experienced emotion (empathy) driving learning and 2) a shared mindset and parallel feelings of peer observers and active participants. Peer observers\u0026rsquo; emotional and cognitive accounts for, and about the active participants, indicate that SBE can elicit empathy between peers.\u003c/p\u003e\u003cp\u003e The significance of an overlap between vicarious and active participation in simulated learning, particularly in the peer observer role, prompts possible re-evaluation of current debriefing practices. Currently, the two roles are considered as discrete experiences and are reported as such in the literature, with standards for simulation design omitting the observer role.\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e This research confirms the value of including peer observers in the simulation experience,\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e but recommends educators extend the scope of debriefing to include explicit identification of empathetic accounts from observers, and add this to the simulation learning outcomes, and more broadly to development of therapeutic, person-centred and professional relationships. Our study has captured peer observer thinking as astute yet also aligning with a range of emotional accounts of the active participant. The value of the observer as an empathetic, evaluator of simulation is a desirable professional attribute.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eEducators cannot underestimate the value of students experiencing empathy for patient groups in a learning situation, particularly in a relatively controlled experience of simulation.\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e Debriefing has evolved to recognise emotional processing and empathy for others within the simulation allowing time at the commencement of debriefing for this to take place.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e Under-represented within the current simulation and debriefing approaches is the experience of empathy, by and for peers and the related learning that occurs because of strong emotions such as empathy. The researchers recommend that subject learning outcomes tacitly include empathy experienced by, and for students, as an outcome of simulation-based experiences. This study has shown how simulation, inclusive of both active and peer observer participants allows students to feel and practice empathy for each other, contributing to learning in the SBE. Educators can acknowledge empathy, whether it spontaneously occurs when peer feedback is provided or is facilitator prompted. In this way students in simulation are connecting in a community of practice through their experience of shared empathy. This significant finding supports explicit teaching of this \u0026lsquo;soft skill\u0026rsquo; which is critical for the effective delivery of person-centered care\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e along with teamwork between peers.\u003c/p\u003e\u003cp\u003eSimulation, inclusive of peer observers can build the capacity to transfer empathetic interactions during clinical care by undergraduate students. Debriefing needs to occupy a central role in building this shared connection between observer and participant, reflecting on how it feels to be empathetic and what reaction it elicits (behavioral). Empathy is not universally intuitive and explicit teaching and modelling, as for reflection, needs to occur. \u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e,\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e Similarly learning from strong emotions may be prompted. Ongoing research is required to better understand how empathy-based care can be optimized in simulation as a legitimate mode of learning.\u003c/p\u003e\u003cp\u003eStudents readily identified with their peers when learning was challenging. Simple clinical intention, skill and actions were forgotten when pressure was present. Nuances of the peer observer role require attention to improve vicarious learning and post-simulation quality reflection. The intense emotions and stress response experienced when observing your peers can limit cognitive processing. The authors recommend adjusting debriefing practice to include emotional processing at the commencement of debriefing, for peer observers along with active participants. Learning within cognitive processing post-simulation has been shown to improve when the emotional response to the simulation experience has been elicited, acknowledged and processed.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eA cognitive load has been demonstrated by both peer observers and active participants, which can limit deeper and sustained learning. Whilst this is not a new finding, it suggests that in simulation contexts underestimation of the intensity of immersion continues. The importance of empathy-based learning within a simulation experience can expand the application of simulation as a pedagogy in preparing nursing students for person-centered and holistic care. The opportunity to experience \u0026lsquo;empathic humility\u0026rsquo; is shared within a tribe (sic) of nursing students\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e immersed in simulation.\u003c/p\u003e\u003cp\u003e\u003cb\u003eLimitation of Study\u003c/b\u003e\u003c/p\u003e\u003cp\u003eQualitative data of peer observer and active participant's thinking was a snapshot from a moment in time, post-simulation completion. Data collected at one time point, is limited in establishing relationships or cause and effect. This study was conducted at a single institution which may limit generalizability. Participant translation of thinking to practice was not captured for analysis. Peer-to-peer empathy and the role empathy played in cognitive processing were the main findings of this study and although the authors pose that this is a transferable skill, this was not explored, limiting inference to application to clinical practice.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eIn summary, the analysis of peer observer and active participant thoughts and reactions captured in this study provided unique insights into students\u0026rsquo; experiences of delivering therapeutic care within a simulated environment. In planning simulation experiences faculty should activate the observer role as an opportunity for prioritizing the art (empathy) and science (cognitive processing of best practice) of holistic nursing care. In this way, the observer role and associated activities are scaffolded to promote active learning over sustaining a passive approach which can limit dynamic interpersonal interactions. Such approaches will maximize exposure to critical elements of holistic nursing, such as empathy-informed care. This study has highlighted how those in the peer observer role can experience simulation as an immersive and emotive experience that may indicate active and deep learning is occurring. As faculty, we can improve nursing students' capacity to apply empathy in practice by creating simulations that harness/target the experience of empathy (art) alongside the science of therapeutic care (cognition processing).\u003c/p\u003e\u003cp\u003eAdditionally, if such experiences mirror the learning active participants achieve and if this enables later transfer of learning to real care contexts, it is an area for future investigation.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical Approval and consent to participate:\u0026nbsp;\u003c/strong\u003eThis study was reviewed and approved by Queensland University of Technology (QUT) Human Research Ethics Committee, with the approval number: 1400000499. Participants consented to study participation with completion of the survey. The study was conducted in accordance with the QUT Code for Responsible Conduct of Research https://mopp.qut.edu.au/document/view.php?id=154 which complies with the Australian Code for the Responsible Conduct of Research 2018 https://www.nhmrc.gov.au/about-us/publications/australian-code-responsible-conduct-research-2018\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication:\u0026nbsp;\u003c/strong\u003eNo individual identifiable data has been included in this manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest:\u0026nbsp;\u003c/strong\u003eNil\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: This study was funded by a Sigma Theta Tau Nurse Education Grant; however, the authors agree this funding did not influence the study process or outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCredit Author Statement:\u0026nbsp;\u003c/strong\u003eNaomi Tutticci: Conceptualization, Methodology, Formal Analysis, Investigation, Writing \u0026ndash; Original Draft, Writing \u0026ndash; Review \u0026amp; Editing, Funding acquisition. Sandra Johnston: Conceptualization, Methodology, Writing \u0026ndash; Original Draft, Writing \u0026ndash; Review \u0026amp; Editing. Joanne Ramsbotham: Conceptualization, Methodology, Writing \u0026ndash; Original Draft, Writing \u0026ndash; Review \u0026amp; Editing. Karen Theobald: Conceptualization, Methodology, Formal Analysis, Investigation, Writing \u0026ndash; Original Draft, Writing \u0026ndash; Review \u0026amp; Editing.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHenry D. Rediscovering the art of nursing to enhance nursing practice. 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The empathy continuum: an evidenced-based teaching model derived from an integrative review of contemporary nursing literature. J Clin Nurs. 2020;29(7\u0026ndash;8):1026\u0026ndash;40. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/jocn.15137\u003c/span\u003e\u003cspan address=\"10.1111/jocn.15137\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"advances-in-simulation","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"asim","sideBox":"Learn more about [Advances in Simulation](http://advancesinsimulation.biomedcentral.com/)","snPcode":"41077","submissionUrl":"https://submission.springernature.com/new-submission/41077/3","title":"Advances in Simulation","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Peer observer, simulation, nursing, pre-registration, empathy, holistic","lastPublishedDoi":"10.21203/rs.3.rs-7042715/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7042715/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eThere is limited evidence and humanistic thinking about the thoughts and reactions of peer observers during nursing simulation. An increased understanding may provide new insights and opportunities to advance therapeutic relationships and holistic care. This study explored peer observer and active participant thoughts during simulation to better understand how shared learning experiences transform and improve nursing practice.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA qualitive descriptive design generated data via peer observers and active participants\u0026rsquo; self-reported experiences from pre-registration second-year, nursing students. Responses were synthesized and analyzed using reflexive thematic analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eFrom 175 peer-observer accounts, four codes were generated and synthesized into three themes: Observer self-critique and critique of others; observer empathy and affect; and observers\u0026rsquo; outsider perspective. Six codes were generated from the analysis of 234 active participant accounts analysis and synthesized into three themes: participant affect; participant cognition and participant confidence.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eThe peer observer role can experience simulation as an immersive and emotive encounter that may indicate active and deep learning is occurring. Simulation learning design should prioritize the identification of empathy experienced by observers for the participants and explicitly include it in cognitive processing undertaken during simulation debrief. Linking the experience of empathy with nursing theory in simulation is a powerful learning tool.\u003c/p\u003e","manuscriptTitle":"An Immersive Mirror: A Descriptive Study of Peer Observer and Active Participant Experiences in Simulation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-11 10:04:32","doi":"10.21203/rs.3.rs-7042715/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-05T06:42:17+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-03T12:12:25+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-25T03:16:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"178999286307371075383323067134423713733","date":"2025-08-14T04:26:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"82294455202033777048066854818409433649","date":"2025-08-06T00:49:21+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-05T23:36:16+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-21T12:43:21+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-21T12:40:24+00:00","index":"","fulltext":""},{"type":"submitted","content":"Advances in Simulation","date":"2025-07-04T03:42:31+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"advances-in-simulation","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"asim","sideBox":"Learn more about [Advances in Simulation](http://advancesinsimulation.biomedcentral.com/)","snPcode":"41077","submissionUrl":"https://submission.springernature.com/new-submission/41077/3","title":"Advances in Simulation","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"bfe085d8-e874-470d-9c60-3170e246ce2a","owner":[],"postedDate":"August 11th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-08T15:59:39+00:00","versionOfRecord":{"articleIdentity":"rs-7042715","link":"https://doi.org/10.1186/s41077-025-00395-7","journal":{"identity":"advances-in-simulation","isVorOnly":false,"title":"Advances in Simulation"},"publishedOn":"2025-12-02 15:57:11","publishedOnDateReadable":"December 2nd, 2025"},"versionCreatedAt":"2025-08-11 10:04:32","video":"","vorDoi":"10.1186/s41077-025-00395-7","vorDoiUrl":"https://doi.org/10.1186/s41077-025-00395-7","workflowStages":[]},"version":"v1","identity":"rs-7042715","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7042715","identity":"rs-7042715","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}