Introduction

Complex medical and nursing training scenarios can be practised in a safe and controllable environment using complex high-tech simulator manikins [1]. Those simulator manikins are designed to enhance a physical appearance with functional task alignment [2]. High-tech simulator manikins are used with the intention to increase students’ understanding of theoretical concepts through practical application and improve students’ engagement and motivation through interactive learning experiences [3]. However the faces of high-tech simulator manikins, like Laerdal’s Nursing Anne Simulator, usually appear generic, impersonal and unreal (Picture 1), especially since a person’s face carries profound personal information and makes a patient and their case memorable [4]. As a consequence, a generic and lifeless face can negatively influence the students’ learning experience [5]. Meerdink and Kahn [6] reported that learners have difficulties engaging with a manikin as if it were a real patient. A lack of realism can act as a mental barrier and prevent participants from fully engaging in the learning scenario [6].

Realism in simulations, in turn, increases the closer a simulation resembles reality, or at least the learners’ mental representation of reality [1]; or in other words, to what extent a copy resembles the original [7]. Taking a more conceptual look at realism, Thistlethwaite [8] states that realism is not only based on individual perceptions but combines ontological realism with epistemological constructivism. This means that realism recognizes the existence of an objective (ontological) reality, but also acknowledges that our knowledge and understanding of this reality is constructed by our individual perceptions and cognitive processes (epistemological constructivism). Nestel et al. [9] argue that there are no hard and fast rules about what needs to be real in simulation. Important is clarity about the simulation’ purpose, from which deliberate decisions about realism can be made. In fact, realism in purposeful simulations allows learners to perform a task rather than pretending to be performing it. One explanation for the positive impact of realism in simulations is that a flow state can be triggered in the student. Flow is understood as a state of highest concentration and absolute immersion in the current activity [10]. Dimitriadou et al. [11] describe flow as a psychological state characterized by complete absorption and focus during an activity, which plays a crucial role in students’ learning effectiveness. Flow positively influences students’ cognitive emotional and behavioural engagement. Engagement has been found to mediate the effects of perceived challenge and interaction on student learning. Engagement and concentration in education are closely aligned as they both play vital roles in the learning process. Engagement is essential for effective knowledge acquisition and societal impact. Concentration, on the other hand, is crucial for maintaining focus and absorbing information during educational activities [12]. Students who experience intense concentration and absorption in the simulation activity, known as flow, learn better and are more satisfied overall [13,14]. Flow optimizes mental state, and enhances students’ adaptability in simulations [14]. Karwowsky [15] argues that when learners achieve a flow state, they are immersed in learning activities, face challenges proactively, and thus exhibit better learning achievement. Flow has been referred to as the optimal experience when nothing else matters [16,17]. This characterization has led to the belief that flow is a particularly intense – and therefore extreme – experience, which makes immersion a prerequisite to flow [18].

There is some evidence that highly realistic moulages can enhance the students’ immersion into a simulation [19]. In addition, Stokes-Parish et al. [20] showed that moulages can increase the realism of learning situations if the given moulages’ lifelikeness is ensured. Further, Stokes-Parish et al. [20] stated that the use of highly lifelike moulages impacts students’ prioritization and task completion in simulations and conclude that moulages can have an essential role to improve realism and subsequent learner engagement [20,21]. These experiences from using moulages in simulation-based education motivated the authors to produce a lifecast moulage face to give a high-tech simulator manikin an individual face during simulation. Several companies now sell face masks for high-tech simulator manikins and though is little evidence on their influence on learners.

The present study thus aims to examine to what extent a high-tech simulator manikin with a real-to-life moulage face-mask influences learners’ flow experience in simulated encounters. We assume that the learners’ flow experience will be meaningfully increased when they are faced with a lifelike moulage face mask.

Methods

A randomized controlled research design was used. Eligible nursing students were allotted to an experimental group (simulation training with manikin wearing a lifelike face mask vs. original generic face) (Figure 1).

Figure 1:

Research design

Results

Participants assigned to the experimental group experienced significantly higher flow (M = 4.2, standard deviation [SD] = 0.89) compared to participants from the control group (M = 3.1, SD = 0.72; U = 12.5, p < 0.05). In addition, participants from the experimental group experienced significantly higher degrees of fluency (M = 3.95; SD = 1.14) compared to the control group (M = 2.59, SD = 0.57; U = 11.5, p < 0.01). No further effects were detected.

Table 1:

FSS items [23]

1	I feel just the right amount of challenge
2	My thoughts/activities run fluidly and smoothly
3	I don’t notice time passing
4	I have no difficulty concentrating
5	My mind is completely clear
6	I am totally absorbed in what I am doing
7	The right thoughts/movements occur of their own accord
8	I know what I have to do each step of the way
9	I feel that I have everything under control
10	I am completely lost in thought
11	Something important for me was at stake
12	I was not allowed to make mistakes
13	I was worried about failure

Spontaneous feedback during the debriefing included remarks such as: ‘I was immediately startled because it looked very real. The face even resembled the person in the film, which made it very realistic’. ‘I thought the patient I saw in the film looked like the manikin, which made it more real’. ‘The fact that it was exactly the face I recognized from the film was very unexpected. But I thought it was very good’, and ‘because the manikin looked like the patient in the video, I was able to immerse myself better in the simulation’ (authors’ translations).

Discussion

In this study, nursing students encountered either a high-tech simulator manikin with its original, generic face, or the same manikin, but with a lifecast face modelled from an actor. Learners from the intervention group achieved significantly higher scores on the FSS’s general flow dimension as well as its fluency sub-dimension. This implies that using a lifecast facemask on a high-fidelity manikin in simulation training increases students’ flow experience. Since a sufficient flow experience can be considered a prerequisite for effective learning, this adds an opportunity for learning facilitators in simulation to support their students’ learning [10,15]. No significant differences between the two groups were found for the sub-dimension’s absorption and anxiety. We take it that a similar level of absorption indicates that both learner groups, irrespective of the manikin’s face, were able to sufficiently engage with the simulation, and that any anxiety experienced was not attributable to the intervention. It could be beneficial when designing a simulation-based learning intervention, to keep flow as a concept in mind. Flow, as a state of full immersion in an activity, has the potential to enhance learning and engagement. Taking a broader view, towards evidence from gaming and serious gaming literature, we learn how it is important to balance task difficulty with player abilities to promote flow: according to Nakamura and Csikszentmihalyi [25], flow occurs when skill level matches the challenge: excessive challenge causes anxiety, while insufficient challenge leads to boredom. In our sequential simulation, tasks were designed to balance students’ skills with the activity’s challenges, ensuring active engagement. It is still important to bear in mind how interruptions negatively impact flow and fluency, disrupting this balance and reducing engagement.

Our research results provide findings about how a lifecast face positively influences nursing students’ flow experience during simulation training. However, some limitations are worth noting. The sample size in this investigation was rather small, while literature confirms [10,15] that a flow experience has a positive impact on student learning, we have no post-intervention performance measure to indicate if the intervention has a relevant impact on students’ learning. Though we applied robust statistics to take the limited sample size into account, it is without doubt that further studies are necessary to replicate this intervention on a larger scale and with a more diverse learner population. A follow-up assessment of performance, for example, utilizing a controlled cross-over design, could determine the impact this intervention might have on learning outcomes. We envision an observer checklist documenting performance not only in scenario-specific competencies but also in more general interpersonal competencies like relationship building and prosocial behaviour. An interesting focus of such a follow-up could also be the question of ‘how much flow is enough?’, as the authors were unable to find any indication on the exact nature of flow, if learners must pass a certain threshold of flow to effectively learn from simulation, or if a further increase of flow further increased learning. In addition, qualitative research should capture students’ emotional responses regarding the use of a personalized lifecast face, until then simulation debriefing should be wary of unintended effects on learners.

Lastly, modelling one’s own lifecast facemask is no easy task and requires knowledge, skills and experience most simulation experts do not have. In our case, it took a professional make-up artist around 150 hours to develop the mask plus relevant resources for materials. Of course, this mask was made to fit Laerdal’s Nursing Anne on its backside for perfect fit, simpler masks that just show a face in the front but are flat on their backside would be easier to produce. These resources must be considered, as individualizing a simulator manikin means that using that mask again with the same learners might be bizarre when introducing that face as a different patient.

Conclusion

Our study found that a personalized manikin increases the students’ flow experience during simulation training.

Since flow is associated with immersion [26], which in turn is associated with proper task performance, the personalization of manikins’ faces could provide facilitators with an additional option to support learners in simulation. Further studies should explore if the increased flow experience leads to better learning outcomes. This study further suggests educators be mindful of the mechanics underlying simulation and actively model their simulation to maximize learning.