A biologically safe, noninvasive method for visualizing bone and soft tissue relationships has been developed recently. Termed the ultrasonic transmission imaging system, its advantages include visualization of soft tissues in real time while motion is underway. The image can be correlated to standard x-ray films, but since no ionizing radiation is involved, repeated risk-free visualization of extremities for either diagnostic assessment or biomechanical studies is permitted. Resolution of 1 mm and a depth of field of 8 mm are adequate for visualization of neurovascular bundles, tendons, ligaments, bones, and joints. The image can be digitized and stored for later analysis on computer graphic systems. Pilot studies have correlated the ultrasonic anatomy of normal and abnormal living and cadaver hands with known anatomic structures. The benefits to biomechanical analysis include the ability to visualize and accurately measure in a noninvasive manner the in vivo changes of position of tendons and other structures during movement. These initial efforts indicate the growing diagnostic and analytic capabilities of this instrument.

SUMMARY STATEMENT:On-site interprofessional education (IPE) simulation is primarily used to teach students teamwork, communication, and crisis resource management. Participants view it as an educational environment in which to acquire and consolidate skills. Virtual IPE simulation is traditionally seen as an opportunity to supplement, complement, and reinforce on-site IPE (OI). We used VI as the sole simulation method during the COVID-19 pandemic to provide IPE because of constraints of social distancing. The VI resulted in substantially achieving similar learning outcomes to OI. This suggests that VI, which has the advantage of being cheaper and more easily scalable than OI, may be an effective remote learning modality for IPE.

© Author(s) (or their employer(s)) 2021. Reuse permitted under CC BYNC. No commercial reuse. See rights and permissions. Published by BMJ. Although media coverage of the COVID-19 crisis may have gradually desensitised us to the daily updates on numbers of cases and deaths, broadcast interviews with distraught frontline health workers continue to evoke an empathic response as we hear about the traumatic conditions of their experiences. It is natural to ask how greater foresight and preparation might have mitigated their emotional distress. In the major pandemic epicentres, even the most experienced emergency physicians confide that they have never before tried to deal with the stress of caring for the pressing needs of overwhelming volumes of patients with gutwrenching illness and rapid progression of disease, amplified by inadequate staffing and a shortage of essential supplies. These conditions create internal struggles and unusual mental health challenges for the affected physicians. The director of the COVID-19 response at the University of CaliforniaSan Francisco Medical Centre emergency department recently explained how the lockdown and burnout are still wearing on her and her colleagues: “Nine Months Into It, the Adrenaline Is Gone and It’s Just Exhausting”. It is accordingly appropriate to ask how our emergency physicians and other frontline health professionals might have been better prepared for the ongoing unique, high intensity and unexpected circumstances. We propose here an approach to learning from the current situation so that, with the development of new immersive training technologies, our emergency health workers might better anticipate and be more resilient when dealing with intense and prolonged experiences that may entail watching their coworkers become ill and even die (similar to warrelated posttraumatic stress disorder (PTSD) and its associated sequelae). Specialised knowledge and skills of emergency physicians distinguish them as experts in dealing with complex situations under uncertainty and time pressure. When such physicians are confronted with unexpected situations, their organised knowledge allows them to respond adaptively and flexibly to the constraints of a rapidly changing environment, demonstrating instinctive responses to highintensity circumstances. The novelty of the required decisions or interventions, the simultaneity of multiple such challenges and a barrage of expectations from others, including fellow workers, patients and their families, exacerbate the situation. Such an environment, with constant tradeoffs, can contribute to significant emotional distress and burnout. 5 Others have drawn parallels between preparing emergency physicians for extreme circumstances and training airline pilots to handle unique and unforeseen emergencies that can occur in the air. Commercial pilots undergo innovative virtual training and evaluation to develop and maintain their skills, and the industry has developed and leveraged advanced simulation methods to mimic the experience of realworld flight operations. Such simulators are designed not only to train pilots regarding new aircraft or instruments but also to give them experiences designed to prepare them for unexpected situations, and the cognitive pressures, that can arise midflight, on landing or during takeoff. While recognising that there are differences between aviation and healthcare, we believe that our recent COVID-19 experience suggests that emergency physicians may benefit from similar training and evaluation on simulators designed to capture the emergency room experience and its most stressful aspects, thereby building resiliency. Medicine has recognised that the useful role of simulations in clinical education, including the creation of simulated patients for learning how to interview and examine coright.

Summary Statement Despite evidence that learners vary greatly in their learning needs, practical constraints tend to favor ''one-size-fits-all'' educational approaches, in simulation-based education as elsewhere. Adaptive educational technologies - devices and/or software applications that capture and analyze relevant data about learners to select and present individually tailored learning stimuli - are a promising aid in learners' and educators' efforts to provide learning experiences that meet individual needs. In this article, we summarize and build upon the 2017 Society for Simulation in Healthcare Research Summit panel discussion on adaptive learning. First, we consider the role of adaptivity in learning broadly. We then outline the basic functions that adaptive learning technologies must implement and the unique affordances and challenges of technology-based approaches for those functions, sharing an illustrative example from healthcare simulation. Finally, we consider future directions for accelerating research, development, and deployment of effective adaptive educational technology and techniques in healthcare simulation.

Immersive learning environments that use virtual simulation (VS) technology are increasingly relevant as medical learners train in an environment of restricted clinical training hours and a heightened focus on patient safety. We conducted a consensus process with a breakout group of the 2017 Academic Emergency Medicine Consensus Conference "Catalyzing System Change Through Health Care Simulation: Systems, Competency, and Outcomes." This group examined the current uses of VS in training and assessment, including limitations and challenges in implementing VS into medical education curricula. We discuss the role of virtual environments in formative and summative assessment. Finally, we offer recommended areas of focus for future research examining VS technology for assessment, including high-stakes assessment in medical education. Specifically, we discuss needs for determination of areas of focus for VS training and assessment, development and exploration of virtual platforms, automated feedback within such platforms, and evaluation of effectiveness and validity of VS education.

Background Health professions education (HPE) is based on deliberate learning activities and clinical immersion to achieve clinical competence. Simulation is a tool that helps bridge the knowledge-to-action gap through deliberate learning. This paper considers how to optimally engage learners in simulation activities as part of HPE. Methods The Simnovate Engaged Learning Domain Group undertook 3 teleconferences to survey the current concepts regarding pervasive learning. Specific attention was paid to engagement in the learning process, with respect to fidelity, realism and emotions, and the use of narratives in HPE simulation. Results This paper found that while many types of simulation exist, the current ways to categorise the types of simulation do not sufficiently describe what a particular simulation will entail. This paper introduces a novel framework to describe simulation by deconstructing a simulation activity into 3 core characteristics (scope, modality and environment). Then, the paper discusses how engagement is at the heart of the learning process, but remained an understudied phenomenon with respect to HPE simulation. Building on the first part, a conceptual framework for engaged learning in HPE simulation was derived, with potential use across all HPE methods. Discussion The framework considers how the 3 characteristics of simulation interplay with the dimensions of fidelity (physical, conceptual and emotional), and how these can be conveyed by and articulated through beauty (as a proxy for efficiency) as coexisting factors to drive learner engagement. This framework leads to the translation of deliberately taught knowledge, skills and attitudes into clinical competence and subsequent performance.

Augmented reality and virtual simulation technologies in nursing education are burgeoning. Preliminary evidence suggests that these innovative pedagogical approaches are effective. The aim of this article is to present 6 newly emerged products and systems that may improve nursing education. Technologies may present opportunities to improve teaching efforts, better engage students, and transform nursing education.

Augmented reality and virtual simulation technologies in nursing education are burgeoning. Preliminary evidence suggests that these innovative pedagogical approaches are effective. The aim of this article is to present 6 newly emerged products and systems that may improve nursing education. Technologies may present opportunities to improve teaching efforts, better engage students, and transform nursing education.

Following their introduction at the beginning of the 21st century, interactive or dynamic Virtual Patients are beginning to be used more widely in clinical education. They can be seen as being at the end of a continuum of simulation technical complexity, having been earlier developed on a wide range of "media": human actors, paper, video, physical mannequins, etc. This paper focuses on the current emergent more complex Virtual Patients in three-dimensional (3D) immersive clinical environments. In these environments, in silico 3D patient avatars interact directly in response to virtual clinical interventions undertaken by avatars, each of which is controlled by one or more users. The paper explores the issues of authoring, deploying, and managing these real-time, dynamic Virtual Patients using as an example the immersive clinical environment CliniSpace. As clinician-accessible Virtual Patient authoring is now becoming available in immersive clinical environments, so these wider clinical and managerial non-technical issues are coming rapidly to the fore.

Background/context Clinical Inter-professional education (IPE) is, by definition, a complex and resource intensive experience to both develop and to deliver. Its’ importance, as a required component of a clinical curriculum, is the core around which the delivery of a realistic health care team experience should be centred. The aim of this paper is to showcase an innovative deployment of IPE to clinical professionals outside the US. The Charles R. Drew University/UCLA School of Medicine have developed an innovative model using virtual world and virtual patient technologies and from this have implemented an alternative framework for delivery. Methodology This framework deploys two technologies to deliver IPE. Virtual world technology enables clinical specialists and students to be ‘virtually’ co-present inside a ‘virtual ward’. ‘Virtual patient’ technologies provide students with multiple ‘patients’ running pathophysiological models that the students can interact with to assess and treat in real time inside these ‘virtual wards’. As importantly these two technologies are combined in single platform, CliniSpace, that can now be modified and deployed by mainstream clinical educators to suit the levels of the learners. A comparative study was designed, developed, delivered and assessed using a randomised research design based on two matching groups of healthcare students. Results/outcomes In summary, and on the basis of the results of this preliminary study, it was shown that on-site IPE can be delivered more effectively than using traditional delivery methods. Potential impact Whilst the specific focus of this study was to demonstrate the relative effectiveness of a new mode of delivery for IPE, at the same time it was noted that it was substantially less resource intensive than the traditional labour intensive IPE delivery approaches. This has significant potential implication in lowering barriers to the future wider and regular deployment of IPE. References Mitchell P, Wynia M, Golden R, McNellis B, Okun S, Webb CE, Rohrbach, V, Von Kohorn I. Core principles & values of effective team-based health care. Discussion Paper, Institute of Medicine, Washington, DC, 2012, www.iom.edu/tbc King S. et al. Developing interprofessional health competencies in a virtual world. medical education online, [S.l.], v. 17, nov. 2012. ISSN 1087-2981. Available at: http://med-ed-online.net/index.php/meo/article/view/11213 Shoemaker M, Platko C, Cleghorn S, Booth A, Virtual patient care: an interprofessional education approach for physician assistant, physical therapy and occupational therapy students. J Interprof Care 2014;28(4):365–367