Perception of simulation-based first-aid training by medical students: a qualitative descriptive study

Although first aid should be common knowledge for healthcare professionals, medical students still have gaps in this area. Simulation-based first-aid courses can overcome these shortcomings. To better understand the impact of these courses, they need to be researched both in terms of learning outcomes and overall participant perception. We conducted fifteen semi-structured interviews with students who completed the First-Aid Simulation Course or the Practical First-Aid Course. The questions focused on the perception of communication, emotional aspects, teamwork, debriefing and the overall administration of the courses. To find the answers to the research questions, we used the qualitative descriptive study design following the principles of inductive thematic analysis. Our findings confirm that many factors impact the performance of students in crisis situations during a simulation-based first-aid course. Four main themes were identified through which the participants perceived the simulation-based first-aid courses. These were team dynamics, fidelity perception, emotional strain and debriefing.


Introduction
Acute conditions and traumatic injuries are globally the most common causes of death. Every day, car accidents result in 3700 deaths worldwide (CDC 2019). In the USA, 795 000 people a year suffer a stroke, while one person succumbs to cardiovascular disease every 36 s (CDC 2018;Virani et al. 2020). These are also the most common causes of death in Europe (Timmis et al. 2020). In the case of a cardiac arrest, timely first aid provided within four minutes may dramatically increase the chances of saving a life (Afzalimoghaddam et al. 2014). Unfortunately, most of the time, adequate first aid is not provided because bystanders lack the knowledge and skills required (Nolan et al. 2015;Merchant et al. 2020). Special procedures recommended by professional bodies should be followed while providing first aid. This standardisation is covered by various organisations, namely the International Liaison Committee on Resuscitation (ILCOR) (International Liaison Committee on Resuscitation 2021) and other affiliated institutions, such as the European Resuscitation Council (ERC) and American Heart Association (AHA). As the above-mentioned procedures are regularly updated, attending specialised first-aid courses are required to acquire and improve life-saving skills. Basic Life Support (BLS) technique training is emphasised, consisting of the following skills: opening the airway, ensuring breathing and retaining circulation by indirect cardiac massage (Olasveengen et al. 2020).
While this skill is not commonplace for the general public, it should be among the basics for healthcare professionals (Saquib et al. 2019). However, medical students, as well as other healthcare professionals, often show limited knowledge in this area (Forouzan et al. 2018;Ghanem et al. 2018;Willmore et al. 2019;Oteir et al. 2019;Irfan et al. 2019).
The solution could lie within the choice and design of suitable teaching methods. For BLS, simulations have proven successful (Ruesseler et al. 2010;Frangez et al. 2017) and allow medical students to practice clinical skills without risk to human health and life (Aggarwal et al. 2010;Datta et al. 2012). Additionally, the students undergo emergency situation drills, obtain teamwork skills and improve communication and psychomotor proficiency (Nestel and Kelly 2018).
In medical education, simulations as educational interventions are considered more efficacious compared to traditional training groups (Henriksen et al. 2018). If high-fidelity simulations are used for cardiopulmonary resuscitation (CPR) training, medical students tend to achieve results that come closer to the ideal set by the American Heart Association's CPR Guidelines, compared to standard training with a low-fidelity simulator (McCoy et al. 2019). Analogically, when problem-based learning combined with high-fidelity simulations is used, students' results come closer to the ILCOR and ERC guidelines, compared to traditional CPR-teaching techniques (Berger et al. 2019).
All learning activities and processes take place in a learning environment (LE). This term encompasses all the aspects of teaching and learning (Shochet et al. 2013;Ahmed et al. 2018;Rusticus et al. 2020). Besides the layout and organisation of the space where the learning takes place, it involves the psychological, social and cultural aspects of teaching and learning (Fayed et al. 2022;Rusticus et al. 2022;Negash et al. 2022). The learning environment impacts the students' engagement, motivation and performance (Bakhshialiabad et al. 2015;Desai et al. 2022). Studies of the students' perception of the LE are the best way to evaluate it and to identify its impacts on the educational activities (Shrestha et al. 2019). The resulting insights into the students' perception of LE may serve as a tool for improving courses, educational programmes and curricula (Barattucci and Bocciolesi 2018).
Most of the existing studies on the perception of BLS have a highly specific focus, although there are exceptions, such as Freund et al. (2013a). The focus is usually on CPR (Troy et al. 2019;Ballesteros-Peña et al. 2020), on healthcare professionals who have completed their education (Abelsson et al. 2018), on how the courses are run (Xie et al. 2019;Hassan et al. 2021) and on student confidence (Freund et al. 2013b). With simulation-based first-aid courses, the studies mostly focus on participants who are not healthcare professionals (Avau et al. 2022) and on secondary school students (Cheng et al. 2021).
On the other hand, the objective of this study is to explore the bigger picture of medical students' perception of simulation-based first-aid training. We aim to understand the students' view of how the course is run and their perception of the learning experience including the communication and emotional aspects.
With this objective in mind, we set four research questions: 1. How do medical students perceive team communication during simulation-based first-aid training? 2. How do medical students perceive the organisation of simulation-based first-aid training? 3. How do medical students perceive the emotional aspects of simulation-based first-aid training? 4. How do medical students perceive their own learning in simulation-based first-aid training?

Methodology
To explore the medical students' perception of simulation-based first-aid training, we chose the descriptive qualitative study design (Doyle et al. 2020). Our research methodology follows the principles of thematic analysis set by Clarke (2006, 2019) and allows for the collection of rich data that can provide a comprehensive view of how the study participants perceive their educational experience (Kim et al. 2017;Cristancho et al. 2018). The qualitative methodology used in this study complies with the COREQ checklist (Tong et al. 2007).

Participants and settings
The research was conducted on a data set gathered from fifteen students of General Medicine at the Faculty of Medicine, Masaryk University Brno (FM). Each student attended and finished either the First-Aid Simulation Course (FASC) under the patronage of the Department of Simulation Medicine at FM or the Practical First-Aid Course (PFAC), organised by volunteers from the Youth Tourist Troop Kasiopea in cooperation with the Internal Cardiology Clinic at the University Hospital Brno. The FASC is currently being offered as an elective subject for General Medicine or Dentistry students at FM (offered each semester) while the PFAC is organised independently of Masaryk University. For more details on the participants, see Table 1. The above-mentioned courses both implement simulations using standardised patients (SPs) chosen from FM student volunteers. FM students also participated as lecturers. The most important element of a simulation is a story with an educational goal set in it. In medical education, these simulations are primarily used to imitate real-life situations and clinical practice, which includes communicating with patients or their close persons (Battista and Nestel 2019). The scenarios in both courses are enacted in the form of sudden emergencies at five different stations. For FASC, the stations are designed to provide training in CPR for an adult or a child along with other skills in providing first aid for other life-threatening conditions -stroke, anaphylaxis or carbon monoxide poisoning. Students are given access to e-learning materials concerning first-aid basics before the course.
The stations are located in indoor and outdoor facilities at FM. Finishing the course content at one station should take approximately 25 min. A five-minute scenario is followed by 20 min of structured debriefing led, according to the PEARLS debriefing framework, by a pair of trained student lecturers. The lecturers were trained by a core team of doctors and simulation-based learning specialists from the Department of Simulation Medicine. After familiarising themselves with the administrative guidelines, the students are randomly allocated into three-member teams. Unlike the FASC, the PFAC utilises scenario-based team simulations as the conclusion of an all-day programme. Before attending the simulated scenarios, students have the opportunity to improve their first-aid basics and try out the skills that will later be put into practice. Each scenario has a 15 min time window, including structured debriefing led by a lecturer. The participants are divided into 4-5 member teams. The goal of the PFAC scenarios is to apply basic first-aid techniques, focusing on differential diagnostics based on the specific situation, e.g. CPR practice, treatment of a compound fracture, hypoglycemia, head injury or vehicle crash victim extrication. The entire course takes place in a separate location outside the MU Campus. Although organised independently of FM, the contents and administrative guidelines were created by a physician and an educational specialist, who also provide the SPs with training in their respective role playing, as well as instructing the students in the role of lecturers in how to conduct a structured debriefing. The course takes place once a year in the first half of December. The exception was in 2020 when it was cancelled due to Covid-19 restrictions.

Sampling
Our research was conducted between September 2019 and November 2021. The sampling was conducted in three phases. In September 2019, 55 current FASC course graduates were contacted by email with an interview request. We intended to measure the long-term impact of the courses by contacting those students who had already finished their course within a time interval of six months or more.
Another group of students was contacted immediately after finishing their course, to acquire their statements while the experience was still fresh in their memories. These students were interviewed within 14 days of the course taking place. Thirty students were contacted during December 2019, another 30 at the end of October 2020 and 25 more at the beginning of November 2021.
From the total of 140 students contacted, 12 agreed to give interviews, after which they kindly provided the contact information for some of their classmates who matched the research profile. By using the snowball sampling method, another four graduates of the PFAC course were incorporated into the research sample. With all 1st to 6th-year students now covered, it was not required to conduct the originally intended sampling to fill any gaps.

Data collection
A semi-structured one-on-one interview was chosen as the data collection technique for this qualitative research. The interviews were conducted between October 2019 and November 2021 at a location chosen by each respondent. The locations were mostly cafés at or close to the university campus; in one case, it was a café in the city centre. The duration of the interviews was 40-55 min. All the interviews were conducted by the first author (LP) following the interview guide (see Table 2), which was designed according to the methodology of conducting in-depth interviews (Yeo et al. 2014). At the start of the interview, the participants were informed about the study objectives and content and notified that the study follows the ethical principles of qualitative research. They also signed an informed consent form. All the participants were informed that the interview would be recorded and that the recording would only be used for transcribing the interview. They were reminded that there were no right or wrong answers and that they could refuse to answer at any point in the interview. The students were familiar with the word "debriefing" from the course organisers. For the interview, a more colloquial Czech word (figurant) was used instead of "simulated patient" (SP).
The first author (LP) let the participants answer these questions freely but did not let them depart from the subject. The main questions were all "how" questions, which were supplemented with follow-up and clarifying questions as needed. Two pilot interviews were also conducted and subsequently integrated into the analysis. All the interviews were recorded as audio files with the recordings transcribed verbatim.

Data analysis
The interviews went through this continuous and repeated process until all the data were processed (McCosker et al. 2004). The data interpretation was consulted with the author collective and, in the interest of improving reliability, the coding process was independently carried out by two authors, (LP) and (AP), using the Atlas. ti program, version 7.5.4. This is a standard programme for processing qualitative data. Due to the type of data collected in our study, we used structural coding, which is suitable for processing data from semi-structured interviews and creating general categories (themes) (Saldaña 2016, pp. 98-101).
We used a six-phase inductive process for the thematic analysis as suggested by Braun and Clarke (2006): How would you evaluate the overall organisation of the course?
1. "Familiarizing yourself with your data, 2. generating initial codes, 3. searching for themes, 4. reviewing themes, 5. defining and naming themes, 6. producing the report." The authors LP and AP thoroughly and repeatedly read all the interview transcripts and then divided them into segments with a common meaning. They labelled the participants' statements within these segments with codes and then looked for similarities and differences between these codes and grouped them into categories. After examining these categories, they created sub-categories for each one. Each of the authors performed this process independently of the other and when completed, compared the results and sought consensus over any differences between the two versions. Theoretical data saturation was achieved after fifteen semi-structured interviews because variations in the participants' responses were repeating (McClenny 2020). The number of interviews is in accordance with the general requirements for qualitative research (Baker and Edwards 2012;Guest et al. 2006).

Ethical considerations
In June 2019, an entry permit was approved by both FM MU Brno and the FASC realisation team. Participants were informed of the goals of the research and informed consent to their voluntary inclusion in the research sample was obtained via a signed form. All personal data were anonymised. No patient data were collected. Masaryk University Research Ethics Committee has declared that the project complies with Czech legal regulations and is thus not in need of any further assessment.

Results
The results below are divided into four themes established by the thematic analysis: team dynamics, fidelity perception, emotional strain and debriefing. An overview of the themes and sub-themes can be found in Table 3. Relevant literal transcripts from the interviews were chosen for illustration purposes. The transcripts were adapted from the original Czech into an English approximation, as a non-standard language (e.g. with frequent colloquialisms) used by the participants.

Team dynamics
According to the respondents, the first theme-Team dynamics-is influenced by the team leaders and how they communicate with other members. At the start of the course, the team leader was viewed as an authority, owing to a certain level of natural respect for senior classmates. Junior students usually expect greater competence from their older classmates. This is a natural leader selection process, conducted intuitively and silently. The actual abilities of the team leader chosen are verified during the class via the trial and error method.
P15 (on the distribution of roles): "We didn't explicitly make a plan, who was supposed to do what, we kind of sorted it out internally, everyone for themselves." P9 (on the leader role): "It's always the strongest one… *laughter*. There were three of us in the group, and it was the oldest girl, she was a fifth year I think, and we went with her as the leader, because she knows the most and everything, and then we came and she was doing absolutely nothing, so for example, I started organising stuff and started telling them what to do and where to go, and so it will be the oldest one or the most experienced one, or the one who takes over when someone else is failing." Consequently, the students began to see the leader as a key factor in the creation of an impromptu sequence of activities to perform during a specific emergency. This perspective was consistent, whether the leader remained unchanged throughout the duration of the course or was replaced based on the individual situation and the capability of the participants. Team communication was also perceived as strongly dependent on team role distribution. When the participants identified with their respective tasks, a matrix of responsibility was created. This persisted through the entire course of the class, especially in the teams where the leader remained unchanged. This resulted in a much smoother resolution of each scenario because the participants knew who was going to perform which activity (e.g. calling an ambulance, performing CPR, calming down close persons).

P5 (on communication)
: "In the beginning, it was hard, because we kept interfering with each other's business. Each of us had a different opinion on what was to be done, but I would say that after the first simulation, we'd roughly clarified most of the things. We didn't exactly talk it through, but the cooperation started working better, it went better."

Fidelity perception
The students were deeply immersed in the simulated environment, to the point of becoming completely engulfed in the scenarios. They would perform various tasks with such fervour that they started to ignore that it was a simulation. This effect was eventually observed even in those students who were originally disengaged and aware of the physical limitations of a simulated environment.
P3 (on the environment in general): "For sure, all of the sites required role playing, so it took a while before you could immerse yourself in it, because you could always feel the classroom around you, and not, like in the mother and child scenario, that it wasn't inside a cafe. In this regard, it took a while. But that was maybe the first 20 seconds when you saw the environment, but after that, you could really focus on what you were supposed to do." After a while, these students also became fully focused and engaged. The students appreciated the faithfulness with which their classmates performed their SP roles, be it as injured persons (afflicted by an acute condition) or otherwise involved. This was later reflected in the overall high ratings of the course. In the students' eyes, the fidelity of the scenarios was the crucial aspect, which allowed deep immersion and enhanced their learning experience. P1 (on actors): "During the manipulation with the body, the people (note: SPs) are able to lie down on the floor and pretend that they're not breathing or not reacting to you, and this is what it might look like in a real situation, I think." P11 (on immersion): "I approached it like -I need to act, I'm here right now and I'm not going to think about it too much." However, there were also cases when the environment proved confusing and did not provide enough guidance for a comprehensive perspective of the situation, thereby disrupting the smooth course of the simulation. P1: "That accident, that crashed car, was accompanied by a sound effect of a skid and a collision, so we could imagine the situation. But for me, what was the most incomprehensible, well maybe it was because we neglected the beginning, too, was the car trunk, which was a box that was supposed to have a reflective vest, a triangle etc. in it, which we didn't understand, and we were looking for these things somewhere else."

Emotional strain
Several sources of emotional strain with different effects were identified in both simulation courses. The perception of stress from dramatic emergencies played a central role.
P7 (on stress): "One thing I can remember exactly, because it was really stressing, which really got me, psychologically, and that was when we had to run down a staircase and some young kid was talking to us, saying that he was locked behind a door with two friends, one of whom was not breathing, and we couldn't get through the door, and we were supposed to instruct one of the friends on how to save the other one." P12 (on worrying about other team members during carbon monoxide poisoning simulation): "… there were multiple people in danger, so the pressure to cooperate was much higher. And I was the only one who recognised what to do, so I was stressed, because they (the rest of the team, interviewer's note) didn't get it, and if this was a real situation, they would have been poisoned too and then I'd have to treat them as well." Stress was also perceived as a result of the participants' self-reflection while thinking back on some of the mistakes they made during the simulations. Making a mistake not only resulted in stress but also frustration, confusion or shame.
P2 (on mistakes): "The patient was acting like she had an anaphylactic reaction, like she fell into shock followed by unconsciousness, so I took the pen (note: epinephrine autoinjector), but I used it upside down, so in real life, I would have applied it to my finger and the patient would have got nothing, which is a shocking realisation to me." Senior students reported feeling affected by peer pressure, mostly from their younger classmates, who had expected a higher level of skills and knowledge from them. However, stress also worked as a trigger for proactivity. A successful resolution of a simulated scenario also resulted in positive feelings.
P8 (on positive feelings): "I was feeling hyped up, like, I wanted to do something, quickly, to try and solve it somehow, and it was cool that we tried to distribute tasks among us, so in the end, we felt good that we managed to sort that out correctly."

Debriefing
The participants perceived the debriefing as beneficial to their learning, both in form and content. They welcomed the option of peer-to-peer discussion -as equals, compared to the classic teacher-centred assessments. The debriefing, provided by classmates, was also described as an important learning experience.
P9: "We sat down at the end, and they started to explain what we did right and what was wrong, and they asked us what we thought was right and wrong. It was kind of interactive, which was great." P13 (on debriefing): "I thought the structure was really well set up so that they could give me the best possible feedback, and I admired how super-well they were coordinated." Knowledge obtained this way was assessed as useful, even for the future, i.e. for mandatory first-aid exams. The debriefing along with the participants' self-reflection also served as an impulse for self-study, clarification and correction of some of the issues caused by lack of knowledge during the class.
P10: "Being in this course was retrospectively great, and I have to say that it helped me a lot, even in my exam, first year-second semester. And I didn't have to spend time reading theory because the practice gives you a hundred times more, even if it's just a simulation, compared to reading through slideshows or any materials." In some cases, the participants even decided to enrol in the course in the following years in the role of an SP.
P4: "I've attended the class once as a common student and then I enrolled three times as the actor, who plays the injured people."

Discussion
The qualitative descriptive analysis generated four main themes: team dynamics, emotional strain, fidelity perception and debriefing.

Team dynamics
A certain level of ambiguity has manifested in the perception of the team leader and one's own role in the team-the course participant either identifies or is in inner dispute with them. In the student's eyes, both the form and content of communication were created by the team leader, who directly influenced activities in the team. According to Pallas et al. (2021), dedicated leadership in simulated learning leads to cognitive offload and subsequently improved team performance. Smithson et al. (2020) agree with this principle-he considers both leadership and teamwork to be key competencies, whose improvement should be supported during medical education. This is a manifestation of hierarchisation-typical for medical schools and professions (Vanstone and Grierson 2022). Social bonds between medical professionals (even during their studies) tend to be structured around the fact that the young and the junior respect their older and/or senior colleagues (Salehi et al. 2020). Therefore, effective leadership is the means to enhance team cooperation, consequently leading to the improvement of patient care (Rosenman et al. 2019). Although medical faculties try to incorporate leadership training into their curricula, there is still insufficient information on the impact of these educational activities (Kumar et al. 2020). Leadership and other non-technical skills are as important as clinical skills and can positively influence the effectiveness and efficiency of resuscitation (Buyck et al. 2019).

Emotional strain
In the students' experience, a further factor influencing their simulation-based learning is stress. Reviews concerning this topic have been published (McGuire and Lorenz 2018;Madsgaard et al. 2022). In some cases, stress served as a source of stimulation and more engagement. Madsgaard et al. (2022) refers to the heterogeneity of students' feelings, labelling it as a "rollercoaster of emotions". The intensity of the experience induced by the teaching method was increased overall because events connected with a strong emotion tend to be remembered longer and more precisely (Tyng et al. 2017). However, as this study has confirmed, stress can also have a negative influence during simulations, as it may lead to a decrease in psychomotor skills performance (Russ et al. 2018). The detrimental effects may be prevented by training and the study of relevant theoretical materials. To only connect the emotional aspects of learning with stress would be to oversimplify the issue. Among other emotions experienced by the students were demotivation and disappointment by their own mistakes. As documented by Palominos et al. (2019), mistakes made during simulations tend to be perceived as a frustration factor, which should be avoided. This is where the debriefing facilitators come in-aiming to convert these negative emotions into opportunities for deeper learning (Palominos et al. 2019).

Fidelity perception
Through the work of the SPs, the course participants interviewed assessed the fidelity of the simulation as very high. SPs are a typical example of a high-fidelity simulation, which tends to be incorrectly associated with only high-tech equipment (Tun et al. 2015). In the case of teaching thorax, lung and cardiac examinations, SPs have been shown to be as beneficial as high-fidelity simulators (Tuzer et al. 2016). Paige and Morin (2013) point out that fidelity is a multi-dimensional concept influenced by a whole array of factors. In this context, this is a high level of psychological fidelity, with the SPs serving as its functional attributes (Paige and Morin 2013). Literature also mentions the use of SPs during simulations among various learning-enhancing factors (Slater et al. 2016;Herbstreit et al. 2017;Taylor et al. 2019). Additionally, employing SPs provides a boost to students' self-confidence before entering medical practice (Ogard-Repal et al. 2018).
There were, of course, various factors inhibiting the fidelity perception during a simulation. Physical limitations caused by the arrangement of a classroom or an outdoor area were identified as one such factor, resulting in disrupting the students' immersion. This deficiency in the physical dimension of fidelity can be mitigated by SPs, who can, should the need arise, enter the scenario and provide the participants with additional information to help them fully orient themselves and successfully solve the issue at hand (Paige and Morin 2013). Another way to limit the unwelcome influences on fidelity perception is via prebriefing, which is mostly mentioned in the context of fiction contract and students' psychological safety (Rudolph et al. 2014;Roh et al. 2018). During prebriefing, teachers can point out objects present in the physical environment, whose function in the scenario is liable to be misinterpreted or misunderstood. This can contribute to the desired outcome, where the integrity of the physical dimension of overall simulation fidelity is not disrupted, and the educational goal is more likely to be achieved.

Debriefing and motivation
The participants in this study positively assessed the informal debriefings led by their classmates. This corresponds with the findings of another study, which show that students do not consider peer-facilitated debriefing to be inferior to facultyfacilitated debriefing (Doherty-Restrepo et al. 2018). Literature also mentions that students can debrief their classmates just as adequately as instructors, (Kim and Yoo 2020) which can lead to higher self-efficacy when compared to a debriefing led by experts (Binkhorst et al. 2020). However, there are also risks. The greatest liability is the potential lack of competence of these non-professional debriefers, which may have a key influence on learning. Therefore, it is necessary to make sure that the debriefing personnel are fully trained and mentored (Ng and Lugassy 2020).
The students' motivation and readiness to enter the courses in the role of SPs creates the need for proper training and mentoring as in the case of the debriefers (Keiser and Turkelson 2017). A large number of student volunteers can be viewed as an advantage-saving the costs of hiring professional actors who would require additional training to be able to provide course participants with relevant feedback (Mavis et al. 2006).
At the same time, most students see no difference in the quality of performance, whether the SP role is played by professional or amateur actors (Viret et al. 2016). Additionally, the students have an opportunity to try out for themselves what it is like to be a patient. Experiencing with their own senses what may feel unpleasant or disconcerting could improve their future attitude towards actual patients.

Limitations
While choosing the research participants, any previous experience with simulation-based courses was not taken into consideration. Furthermore, some of the interviews were conducted a relatively long time after the respective participants had finished their courses. As a result, some had difficulties recalling the details. Due to the high workload medical students must contend with, along with increased health and safety requirements caused by the Covid-19 pandemic, it took more than two years to conduct all fifteen interviews and obtain sufficient data. In 2020, due to the Covid-19 pandemic, PFAC was also cancelled, which severely limited the options for contacting potential research subjects. The innate properties of qualitative research also make it impossible to generalise these findings for the entire population of medical students.

Suggestion for further research
As a topic for further research, we suggest the perception of simulation-based first-aid training by lecturers, SPs and faculties. A comprehensive image of the perceptions of all parties involved could be created. Another topic worthy of further research is the perception of emotions and fidelity in simulation-based LE and the impact on learning outcomes.

Conclusion
Our findings confirm that numerous factors impact the performance of students in crisis situations during a simulation-based first-aid course. Team dynamics and communication, including the course and resolution of the simulated situations, depend on the leader. The students felt that their emotional strain resulted not only from stressful emergency situations but from the fear and frustration caused by their mistakes. Using the SPs helped the students to become immersed in the situations and their roles despite the limits caused by the layout and organisation of the learning space. The students' perception of debriefing was positive, and they found it to be a useful evaluation method. These insights into the perception of first-aid training can be used to design (and redesign) these types of courses. The students could be provided with study materials on communication and leadership prior to the course, either through e-learning or in a face-to-face workshop on these non-technical skills. Fidelity could be optimised by stimulating other senses to further enhance the realism of the settings using sound effects, relevant props and characteristic smells. The cues that the participants receive from props and prompts from the SPs during the simulations can overcome the limits of the physical space. The SPs must be trained not to overplay their roles. Their roleplaying must not create unnecessary stress that could hinder the participants and divert their attention away from the educational intent of the course. Although the participants viewed structured debriefing as a valuable and effective evaluation method, the organisers must keep in mind that structured debriefing is not suitable for all simulations. Similarly, these suggestions for redesigning FASC or PFAC cannot be viewed as a universally valid list for all simulation modalities and scenarios.