Table 4 Directed content analysis of narrative text responses in post-session survey

1. Emotions & Reactions to Session

Overall satisfaction and enjoyment of simulation experience despite feeling challenged due to unfamiliar material

“I think it was excellent, small groups are great because it allows for active participation, even if we all felt stretched having to work through something we haven’t done before.” “Breakout rooms were interesting and different, appreciated how it was structured and really enjoyed it.”

Role playing is uncomfortable and demanding but provides participants the opportunity to situate their learning within health system contexts

“We fell into the roles as time went by, and it felt a lot more natural after that, but it did take a few minutes, I feel, to get into it. It made me realize I don’t envy medical directors. I would not want that role in real life, having to please everyone but also respect the bottom line.” “It was really awkward. I don’t think I could have had that conversation as a real person. It was nice to have my fake character to hide behind, to have a first try at doing this stuff before having to do it in real life.”

Virtual format can be awkward due to need for turn-taking and limitations in interactivity

“I felt like the Zoom format made it a bit awkward and we had a lot of silences because it impeded free-flowing conversations and really getting into our roles.” “The small group session was a bit tough on Zoom format, I wonder if we can do this in person things would be smoother.”

2. Feasibility/Applicability of Session and Recommendations for Improvement

Representation and participation from other professions/disciplines would improve fidelity/experience

“More representatives from actual nursing staff…would make the priorities/pitfalls from each stakeholder more realistic.” “Use actual mix of professions. I felt like I was pretending to be a nurse and didn’t really know what they would feel or be worried about.”

Distilling core concepts/teaching points for participants would help translation and long-term absorption of knowledge

“Give us simple handout boiling down takeaway concepts. I’d like to refer to them again in the future.” “Provide more examples of practices to change implementation and some of the case materials by email."

Tailoring of case content/environment to the specific discipline/role of trainees would make simulations more realistic

“Make it more in terms for the emergency department…overall the activity helped show challenges for the outpatient setting but less for the hospital.” “I would like to think more about what my role would be as a surgeon and how I would respond to a serious safety event in the operating room.”

Provide direct support/interaction with session facilitators would help the breakout simulation experience

“Would have been helpful to have a knowledgeable facilitator during the breakout with us…we were having trouble with the budget portion of the scenario.” “Have facilitators in each group please so they can answer questions as we go since the timing was so tight.”

3. Transfer of Knowledge to Bedside

Incorporating multiple stakeholder perspectives is complex and involves negotiation of competing priorities

“Made me think more about my current working environment…helped me understand how challenging it is to work with a multidisciplinary team and still meet timelines, especially thinking about IT support and the budget needed to make it happen.”

Successful negotiation requires attending to social/power dynamics and use of practiced techniques like "Best Alternative to a Negotiated Agreement" (BATNA)

“Have to be considerate of others’ priorities…I work on a unit with doctors, clinical psychologists who are PhDs, APRNs, and counselors, each with their own stakes and in some cases unions.” “I feel like I have a good idea of how I would organize and carry out one of these processes using these techniques now, especially with administrators and non-MDs.”

System change is affected by barriers at multiple levels of care delivery and can be influenced by type/nature of incentives

“Interesting to think about the practice of negative and positive incentives.” “Consider how to improve staff buy-in with motivating practice and making sure new practices in “workflow” don’t add to work burden for our nurses.”