| 1. |
- Creutzfeldt, Johan
(författare)
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Avatar : saving lives in virtual worlds
- 2013
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- In medicine, education and recurrent training is fundamental for efficient and safe care. In emergency situations one has to rely on robust protocols that reduce the risk for errors. However, today there is plenty of evidence that the professional level of knowledge, manual, cognitive and teamwork skills as well as suitable attitudes needs to be raised. By using new and promising educational technology it has been proposed that one can address several problems in today’s education and training. So far, in medicine there haven’t been many results on whether gaming technology supports learning although findings from several authors are encouraging. One area of particular interest is that of cardiopulmonary resuscitation (CPR), since all health care professionals are assumed to possess competence in this field. To disseminate the knowledge and skills, with the goal of reaching better outcome after out-of-hospital sudden cardiac arrests, CPR is also trained at schools. With the rapid development in information and communications technology (ICT) and the increase in computer access and skills in a digital native generation, the stage is set for “serious games”. By using cardiopulmonary resuscitation as a model, the aim of this thesis project has been to understand if a virtual world is suitable for training medical and high school students to assist in emergency medical situations. A virtual world with capabilities to train teamwork CPR was developed. Short scenario based training sessions using a virtual school environment was carried out in teams. In study I and II user experiences and reactions were assessed from a social cognitive and games research perspective. The findings in terms of strengthened self-efficacy beliefs and positive ratings on dimensions of “flow” experience indicated that this tool could engage the subjects and carried properties important for learning and execution. Results from Swedish and US high schools were comparable. Study III was a transfer study in which virtual world pre-trained groups were assessed and compared to control subjects in a full-scale high fidelity patient simulator, 6 and 18 months after virtual world CPR team training. Main findings in this study indicated that subjects trained 6 months before simulator assessment delivered higher quality CPR in terms of chest compressions, and followed the CPR protocol better than the other groups. In study IV the aim was to get a more complete picture of how the virtual world CPR team training was perceived by the participants and compare the findings with theories on learning and serious games. Using a qualitative approach, four categories evolved as end result. The findings support many of the proposed benefits of serious games, such as high levels of enjoyment and engagement. Further, learning in teams is beneficial for several reasons. However, there are areas that call for some caution. It can be questioned if a sense of mastery created in a virtual world easily transfers to the real world. Also, not all students are enchanted by computers and computer games – when establishing training in virtual worlds one has to consider the level of computer interest among the users. To evoke the proposed positive effects of virtual world training, one has to meet the demands this game derived method poses in terms of high levels of challenge, proximal goal-setting, affective involvement and rich feed-back. Although being exploratory to its nature, the results from this project demonstrate possibilities within virtual worlds for training in teams. Being accessible, relatively inexpensive to run and rich in variations, virtual worlds based training can be motivated in a variety of settings within medicine.
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| 2. |
- Creutzfeldt, Johan, et al.
(författare)
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Cardiopulmonary Resuscitation Training by Avatars : A Qualitative Study of Medical Students' Experiences Using a Multiplayer Virtual World
- 2016
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Ingår i: JMIR Serious Games. - : JMIR Publications Inc.. - 2291-9279. ; 4:2
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Tidskriftsartikel (refereegranskat)abstract
- Background: Emergency medical practices are often team efforts. Training for various tasks and collaborations may be carried out in virtual environments. Although promising results exist from studies of serious games, little is known about the subjective reactions of learners when using multiplayer virtual world (MVW) training in medicine.Objective: The objective of this study was to reach a better understanding of the learners’ reactions and experiences when using an MVW for team training of cardiopulmonary resuscitation (CPR).Methods: Twelve Swedish medical students participated in semistructured focus group discussions after CPR training in an MVW with partially preset options. The students’ perceptions and feelings related to use of this educational tool were investigated. Using qualitative methodology, discussions were analyzed by a phenomenological data-driven approach. Quality measures included negotiations, back-and-forth reading, triangulation, and validation with the informants.Results: Four categories characterizing the students’ experiences could be defined: (1) Focused Mental Training, (2) Interface Diverting Focus From Training, (3) Benefits of Practicing in a Group, and (4) Easy Loss of Focus When Passive. We interpreted the results, compared them to findings of others, and propose advantages and risks of using virtual worlds for learning.Conclusions: Beneficial aspects of learning CPR in a virtual world were confirmed. To achieve high participant engagement and create good conditions for training, well-established procedures should be practiced. Furthermore, students should be kept in an active mode and frequent feedback should be utilized. It cannot be completely ruled out that the use of virtual training may contribute to erroneous self-beliefs that can affect later clinical performance.
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| 3. |
- Creutzfeldt, Johan, et al.
(författare)
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Cardiopulmonary resuscitation training in High School using Avatars in Virtual Worlds : An International Feasibility Study
- 2013
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Ingår i: Journal of Medical Internet Research. - : JMIR Publications Inc.. - 1438-8871. ; 15:1, s. doi-10.2196/jmir.1715
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Tidskriftsartikel (refereegranskat)abstract
- Background: Approximately 300,000 people suffer sudden cardiac arrest (SCA) annually in the United States. Less than 30% of out-of-hospital victims receive cardiopulmonary resuscitation (CPR) despite the American Heart Association training over 12 million laypersons annually to conduct CPR. New engaging learning methods are needed for CPR education, especially in schools. Massively multiplayer virtual worlds (MMVW) offer platforms for serious games that are promising learning methods that take advantage of the computer capabilities of today's youth (ie, the digital native generation). Objective: Our main aim was to assess the feasibility of cardiopulmonary resuscitation training in high school students by using avatars in MMVM. We also analyzed experiences, self-efficacy, and concentration in response to training. Methods: In this prospective international collaborative study, an e-learning method was used with high school students in Sweden and the United States. A software game platform was modified for use as a serious game to train in emergency medical situations. Using MMVW technology, participants in teams of 3 were engaged in virtual-world scenarios to learn how to treat victims suffering cardiac arrest. Short debriefings were carried out after each scenario. A total of 36 high school students (Sweden, n=12; United States, n=24) participated. Their self-efficacy and concentration (task motivation) were assessed. An exit questionnaire was used to solicit experiences and attitudes toward this type of training. Among the Swedish students, a follow-up was carried out after 6 months. Depending on the distributions, t tests or Mann-Whitney tests were used. Correlation between variables was assessed by using Spearman rank correlation. Regression analyses were used for time-dependent variables. Results: The participants enjoyed the training and reported a self-perceived benefit as a consequence of training. The mean rating for self-efficacy increased from 5.8/7 (SD 0.72) to 6.5/7 (SD 0.57, P<.001). In the Swedish follow-up, it subsequently increased from 5.7/7 (SD 0.56) to 6.3/7 (SD 0.38, P=.006). In the Swedish group, the mean concentration value increased from 52.4/100 (SD 9.8) to 62.7/100 (SD 8.9, P=.05); in the US group, the concentration value increased from 70.8/100 (SD 7.9) to 82.5/100 (SD 4.7, P<.001). We found a significant positive correlation (P<.001) between self-efficacy and concentration scores. Overall, the participants were moderately or highly immersed and the software was easy to use. Conclusions: By using online MMVWs, team training in CPR is feasible and reliable for this international group of high school students (Sweden and United States). A high level of appreciation was reported among these adolescents and their self-efficacy increased significantly. The described training is a novel and interesting way to learn CPR teamwork, and in the future could be combined with psychomotor skills training.
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| 4. |
- Creutzfeldt, Johan, et al.
(författare)
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Effects of pre-training using serious game technology on CPR performance : an exploratory quasi-experimental transfer study
- 2012
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Ingår i: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. - : Springer Science and Business Media LLC. - 1757-7241. ; 20, s. 79-
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Tidskriftsartikel (refereegranskat)abstract
- Background: Multiplayer virtual world (MVW) technology creates opportunities to practice medical procedures and team interactions using serious game software. This study aims to explore medical students' retention of knowledge and skills as well as their proficiency gain after pre-training using a MVW with avatars for cardio-pulmonary resuscitation (CPR) team training. Methods: Three groups of pre-clinical medical students, n = 30, were assessed and further trained using a high fidelity full-scale medical simulator: Two groups were pre-trained 6 and 18 months before assessment. A reference control group consisting of matched peers had no MVW pre-training. The groups consisted of 8, 12 and 10 subjects, respectively. The session started and ended with assessment scenarios, with 3 training scenarios in between. All scenarios were video-recorded for analysis of CPR performance. Results: The 6 months group displayed greater CPR-related knowledge than the control group, 93 (+/- 11)% compared to 65 (+/- 28)% (p < 0.05), the 18 months group scored in between (73 (+/- 23)%). At start the pre-trained groups adhered better to guidelines than the control group; mean violations 0.2 (+/- 0.5), 1.5 (+/- 1.0) and 4.5 (+/- 1.0) for the 6 months, 18 months and control group respectively. Likewise, in the 6 months group no chest compression cycles were delivered at incorrect frequencies whereas 54 (+/- 44)% in the control group (p < 0.05) and 44 (+/- 49)% in 18 months group where incorrectly paced; differences that disappeared during training. Conclusions: This study supports the beneficial effects of MVW-CPR team training with avatars as a method for pre-training, or repetitive training, on CPR-skills among medical students.
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| 5. |
- Creutzfeldt, Johan, et al.
(författare)
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Exploring Virtual Worlds for Scenario-Based Repeated Team Training of Cardiopulmonary Resuscitation in Medical Students
- 2010
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Ingår i: Journal of Medical Internet Research. - : JMIR Publications Inc.. - 1438-8871. ; 12:3, s. e38-
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Tidskriftsartikel (refereegranskat)abstract
- BackgroundContemporary learning technologies, such as massively multiplayer virtual worlds (MMVW), create new means for teaching and training. However, knowledge about the effectiveness of such training is incomplete, and there are no data regarding how students experience it. Cardiopulmonary resuscitation (CPR) is a field within medicine in high demand for new and effective training modalities.ObjectiveIn addition to finding a feasible way to implement CPR training, our aim was to investigate how a serious game setting in a virtual world using avatars would influence medical students’ subjective experiences as well as their retention of knowledge.MethodsAn MMVW was refined and used in a study to train 12 medical students in CPR in 3-person teams in a repeated fashion 6 months apart. An exit questionnaire solicited reflections over their experiences. As the subjects trained in 4 CPR scenarios, measurements of self-efficacy, concentration, and mental strain were made in addition to measuring knowledge. Engagement modes and coping strategies were also studied. Parametric and nonparametric statistical analyses were carried out according to distribution of the data.ResultsThe majority of the subjects reported that they had enjoyed the training, had found it to be suitable, and had learned something new, although several asked for more difficult and complex scenarios as well as a richer virtual environment. The mean values for knowledge dropped during the 6 months from 8.0/10 to 6.25/10 (P = .002). Self-efficacy increased from before to after each of the two training sessions, from 5.9/7 to 6.5/7 (P = .01) after the first and from 6.0/7 to 6.7/7 (P = .03) after the second. The mean perceived concentration value increased from 54.2/100 to 66.6/100 (P = .006), and in general the mental strain was found to be low to moderate (mean = 2.6/10).ConclusionsUsing scenario-based virtual world team training with avatars to train medical students in multi-person CPR was feasible and showed promising results. Although we found no evidence of stimulated recall of CPR procedures in our test-retest study, the subjects were enthusiastic and reported increased concentration during the training. We also found that subjects’ self-efficacy had increased after the training. Despite the need for further studies, these findings imply several possible uses of MMVW technology for future emergency medical training.
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| 6. |
- Creutzfeldt, Johan, et al.
(författare)
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Using virtual world training to increase situation awareness during cardiopulmonary resuscitation
- 2014
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Ingår i: Medicine meets virtual reality 21. - : IOS Press. - 9781614993742 - 9781614993759 ; 196, s. 83-5
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Konferensbidrag (refereegranskat)abstract
- Situation awareness (SA) is a critical non-technical skill which affects outcome during emergency medical endeavors. Using a modified self-report instrument a significant increase of SA was found during multiplayer virtual world CPR team training among 12 medical students. Further a correlation between SA and attention was noted. Being a vital factor during the process of video-game play, we argue that this skill is suitably practiced using this training method.
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| 7. |
- Dubois, Hanna, et al.
(författare)
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Patient participation in gastrointestinal endoscopy : From patients' perspectives
- 2020
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Ingår i: Health Expectations. - : Wiley. - 1369-6513 .- 1369-7625. ; 23:4, s. 893-903
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: Patient participation is associated with satisfaction and improved health-related outcomes. In gastrointestinal endoscopy, patient participation is an underexplored area.OBJECTIVE: To gain understanding on patients' experiences, attitudes and preferences concerning patient participation in the endoscopy pathway.METHODS: Semi-structured interviews with endoscopy patients (n = 17, female n = 8, male n = 9, ages 19-80 years) were performed. Interview transcripts were analysed using qualitative content analysis. Participants were recruited by purposive sampling from an endoscopy unit in a Swedish university hospital. Inclusion:≥ 18 years, fluency in Swedish and recent experience of endoscopy at the unit.RESULTS: Five generic categories emerged, two within the area of the patient's role, which was described as active or passive/included or excluded. Another three generic categories related to factors, critical to active participation, including organizational aspects, impressions of staff and individual circumstances were identified. In this context, patient participation described in the interviews was on a low to basic level, although sometimes reaching a higher level when staff 'invited' patients in decision making.DISCUSSION: This study contributes to the understanding of patient participation in endoscopy. Patients are in an inferior position and need support from the staff for an active role in their care. Although there were variations on the perceived importance of different factors, a heavy responsibility lies on the endoscopy staff to acknowledge the patients' individual needs and to facilitate patient participation.CONCLUSIONS: Endoscopy staff has a key role in supporting patient participation. In endoscopy settings, patient participation is vulnerable to multiple factors.
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| 8. |
- Dubois, Hanna, et al.
(författare)
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Patient participation in tele-emergencies : experiences from healthcare professionals in northern rural Sweden
- 2022
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Ingår i: Rural and remote health. - 1445-6354. ; 22:4
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Tidskriftsartikel (refereegranskat)abstract
- INTRODUCTION: Telemedicine provides opportunities for access to health care in remote and underserved areas. In parts of northern rural Sweden telemedicine is used to connect a remote physician by a video-conference system to an emergency room, staffed by nurses during on-call hours. This can be called 'tele-emergency'. Patient participation, often described as mutual information exchange, a trustful relationship and involvement in decision-making, is challenged in emergency care by short encounters, deteriorating patients and a stressful work situation. Nevertheless, patient participation may be important for the patients' experience. Healthcare professionals (HCPs) have been identified as 'gatekeepers' for patient participation, therefore putting their perspective in focus is important. As emergency care in rural areas is increasingly turning toward telemedicine, patient participation in tele-emergencies needs to be better understood. The aim of this study was to explore and characterise HCPs' perspectives of patient participation in tele-emergencies in northern rural Sweden.METHODS: A qualitative design based on interviews was used. HCPs working in cottage hospitals in northern rural Sweden were included. Semi-structured interviews were performed, first, in multidisciplinary groups of three informants. Later, because of limited experience of tele-emergencies in the groups, individual interviews with HCPs with substantial experience were added. A qualitative content analysis of the interview transcripts was conducted.RESULTS: A total of 44 HCPs from northern inland Sweden participated in the interviews. The content analysis resulted in two themes, six categories and 19 subcategories. Theme 1, 'To see, understand, and to build trust through the digital barrier', contains descriptions of the interpersonal relationship between the patient and the HCPs, and the challenges when interacting with the patient during a tele-emergency. The informants also described a need for boundaries between the professional team and the patient. The categories in theme 1 are 'understanding the patient's point of view', 'building a trustful relationship', and 'needing a private space without the patient'. Theme 2, 'The (im)balance of power - tele-emergency reinforces the positions', mirrors the power asymmetry in the patient-professional relationship, and the potential impact of the tele-emergency on the different roles. Tele-emergencies were described as a risk that potentially could weaken the patient's position, but also as providing an opportunity to share power. Categories in theme 2 are 'medical conditions limit patient participation', 'patient involvement in decision-making requires understanding' and 'the inferior patient and the superior professionals'.CONCLUSION: This study sheds light on patient participation in tele-emergencies in a remote rural setting from the HCP's perspective. The tele-emergency set-up affected patient participation by interfering with familiar patient-HCP relationships and changing group dynamics in interactions with the patient. Due to the extensive changes of the conditions for patient participation imposed in tele-emergencies, suggestions for actions improving patient participation are made.
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| 9. |
- Escher, Cecilia, et al.
(författare)
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All professions can benefit — a mixed-methods study on simulation-based teamwork training for operating room teams
- 2023
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Ingår i: Advances in Science and Technology Research Journal. - : BioMed Central (BMC). - 2364-3277 .- 2059-0628. ; 8:1
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Tidskriftsartikel (refereegranskat)abstract
- Background: Operating rooms have become more technically complex due to new advanced procedures, which has increased demands on teamwork in the operating room. In response, team training has been proposed to improve team performance, workplace culture, and patient safety. We developed and delivered a simulation-based team training course for entire professional surgical teams. This type of intervention has been proposed by researchers but has not been widely published. The aims of this intervention study were to examine participants’ reactions to the course in terms of their motivation for the training and their self-efficacy in relation to their performance, as well as their views on transferring the lessons learned in the course to their workplace.Methods: In a prospective mixed-methods intervention study, operating room professionals participated in a full-day simulation-based teamwork training course. Learning objectives were nontechnical skills, specifically communication and collaboration across the team. Seventy-one staff members representing 5 operating room professions were included, and the average work experience of participants was 6 years. Quantitative data on self-efficacy and situational motivation were collected by questionnaires before and after training. Qualitative data were collected through 5 focus group interviews that took place in direct relation to the courses and included a total of 31 participants. Transcripts were coded and analyzed using thematic analysis.Results: All occupations showed a similar pattern in terms of increases in self-efficacy and intrinsic motivation after the training. Analysis of the qualitative data showed that training in one’s profession and in authentic multiprofessional teams was important factors for motivation. Participating staff described an awareness of undesirable communication barriers in surgical teams that can lead to risks for patients. Systematic training was definitely perceived as a means to reduce barriers and improve communication and collaboration.Conclusion: Simulation-based training was equally well received by all professional groups. Our results confirm the feasibility of this type of training for professional teams and promising opportunities for improving teamwork skills. The qualitative data reveal both opportunities and limitations for transferring the learning experiences to the workplace.
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| 10. |
- Escher, Cecilia, et al.
(författare)
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Fear of making a mistake : a prominent cause of stress for COVID-19 ICU staff-a mixed-methods study
- 2023
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Ingår i: BMJ Open Quality. - : BMJ. - 2399-6641. ; 12:1
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Tidskriftsartikel (refereegranskat)abstract
- IntroductionThe COVID-19 pandemic has had a profound effect on many domains of healthcare. Even in high-income countries such as Sweden, the number of patients has vastly outnumbered the resources in affected areas, in particular during the first wave. Staff caring for patients with COVID-19 in intensive care units (ICUs) faced a very challenging situation that continued for months. This study aimed to describe burnout, safety climate and causes of stress among staff working in COVID-19 ICUs.MethodA survey was distributed to all staff working in ICUs treating patients with COVID-19 in five Swedish hospitals during 2020 and 2021. The numbers of respondents were 104 and 603, respectively. Prepandemic data including 172 respondents from 2018 served as baseline.ResultsStaff exhaustion increased during the pandemic, but disengagement decreased compared with prepandemic levels (p<0.001). Background factors such as profession and work experience had no significant impact, but women scored higher in exhaustion. Total workload and working during both the first and second waves correlated positively to exhaustion, as did being regular ICU staff compared with temporary staff. Teamwork and safety climate remained unchanged compared with prepandemic levels.Respondents reported 'making a mistake' as the most stressful of the predefined stressors. Qualitative analysis of open-ended questions identified 'lack of knowledge and large responsibility', 'workload and work environment', 'uncertainty', 'ethical stress' and 'organization and teamwork' as major causes of stress.ConclusionDespite large workloads, disengagement at work was low in our sample, even compared with prepandemic levels. High levels of exhaustion were reported by the ICU staff who carried the largest workload. Multiple significant causes of stress were identified, with fear of making a mistake the most significant stressor.
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| 11. |
- Escher, Cecilia, et al.
(författare)
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Medical students' situational motivation to participate in simulation based team training is predicted by attitudes to patient safety
- 2017
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Ingår i: BMC Medical Education. - : BIOMED CENTRAL LTD. - 1472-6920. ; 17
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Tidskriftsartikel (refereegranskat)abstract
- Background: Patient safety education, as well as the safety climate at clinical rotations, has an impact on students' attitudes. We explored medical students' self-reported motivation to participate in simulation-based teamwork training (SBTT), with the hypothesis that high scores in patient safety attitudes would promote motivation to SBTT and that intrinsic motivation would increase after training.Methods: In a prospective cohort study we explored Swedish medical students' attitudes to patient safety, their motivation to participate in SBTT and how motivation was affected by the training. The setting was an integrated SBTT course during the surgical semester that focused on non-technical skills and safe treatment of surgical emergencies. Data was collected using the Situational Motivation Scale (SIMS) and the Attitudes to Patient Safety Questionnaire (APSQ).Results: We found a positive correlation between students' individual patient safety attitudes and self-reported motivation (identified regulation) to participate in SBTT. We also found that intrinsic motivation increased after training. Female students in our study scored higher than males regarding some of the APSQ sub-scores and the entire group scored higher or on par with comparable international samples.Conclusion: In order to enable safe practice and professionalism in healthcare, students' engagement in patient safety education is important. Our finding that students' patient safety attitudes show a positive correlation to motivation and that intrinsic motivation increases after training underpins patient safety climate and integrated teaching of patient safety issues at medical schools in order to help students develop the knowledge, skills and attitudes required for safe practice.
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| 12. |
- Escher, Cecilia, et al.
(författare)
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Method matters: impact of in-scenario instruction on simulation-based teamwork training
- 2017
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Ingår i: Advances in Simulation. - : Springer Science and Business Media LLC. - 2059-0628 .- 2364-3277. ; 2:25
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Tidskriftsartikel (refereegranskat)abstract
- Background: The rationale for introducing full-scale patient simulators in training to improve patient safety is to recreate clinical situations in a realistic setting. Although high-fidelity simulators mimic a wide range of human features, simulators differ from the body of a sick patient. The gap between the simulator and the human body implies a need for facilitators to provide information to help participants understand scenarios. The authors aimed at describing different methods that facilitators in our dataset used to provide such extra scenario information and how the different methods to convey information affected how scenarios played out. Method: A descriptive qualitative study was conducted to examine the variation of methods to deliver extra scenario information to participants. A multistage approach was employed. The authors selected film clips from a shared database of 31 scenarios from three participating simulation centers. A multidisciplinary research team performed a collaborative analysis of representative film clips focusing on the interplay between participants, facilitators and the physical environment. After that the entire material was revisited to further examine and elaborate the initial findings. Results: The material displayed four distinct methods for facilitators to convey information to participants in simulation based teamwork training. The choice of method had impact on the participating teams regarding flow of work, tempo and team communication. Facilitators’ close access to the teams’ activities when present in the simulation suite, either embodied or disembodied in the simulation, facilitated the timing for providing information, which was critical for maintaining the flow of activities and learner engagement in the scenario. The mediation of information by a loudspeaker or an earpiece from the adjacent operator room could be disturbing for team communication when information was not well timed. Conclusions: In-scenario instruction is an essential component of simulation based teamwork training that has been largely overlooked in previous research. The ways in which facilitators convey information about the simulated patient have the potential to shape the simulation activities and thereby serve different learning goals. Although immediate timing to maintain an adequate tempo is necessary for professionals to engage in training of acute situations, novices may gain from a slower tempo to train complex clinical team tasks systematically.
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| 13. |
- Kelly, Michelle, et al.
(författare)
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Preparing for Team Work Training in Simulation
- 2019
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Ingår i: Interprofessional Simulation in Health Care. Abrandt Dahlgren M., Rystedt H., Felländer-Tsai L., Nyström S. (red.). - Cham : Springer. - 2210-5549 .- 2210-5557. - 9783030195427 ; , s. 59-89
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Bokkapitel (refereegranskat)abstract
- An important condition for serving the educational objectives of simulation-based team training is that the facilitator’s instructions during the briefing bridge the gap between the simulation and the clinical situation it is intended to represent. This chapter unpacks instructional challenges in briefings by focusing on how instructors make use of trainees’ exhibited understanding of tasks to demonstrate how procedures should be adapted to the specific conditions of the simulation. Further, the chapter addresses the interplay between the simulation scenario, the provision of manikin features and the instructor’s guidance in the scenario and the relation to team performance in the simulation. The chapter shows how additional information is conveyed to the participants during the scenario to overcome the shortcomings of the simulator and how the sequencing and timing of this information during the scenarios were crucial for furthering the participants’ activities.
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