This study indicates that short computer based simulation exercises provide opportunities for head nurses to improve management skills and increase their general self-efficacy.

Funding This work was supported by the Swedish Civil Contingencies Agency (MSB) and The SwedishGovernmental Agency for Innovation Systems (VINNOVA). AcknowledgementsThe authors thank the ETS instructors and simulation participants for enabling and contributing to this study. We also thank the reviewers for clear and constructive criticism that clarified the paper. Lastly, we thank our department colleagues Mattias Kristiansson, Erik Prytz, and Robin Keskisärkkä at Linköping University for our discussions on DCog and DiCoT.

1Designing a digital medical management training simulator using distributed cognition theory 2 Structured abstractBackground: Training of medical professionals is important to improve care during masscausality events. Therefore, it is essential to extend knowledge on how to design valid and usable simulation-based training environments.Purpose: This article investigates how distributed cognition and simulation theory concepts can guide design of simulation-based training environments. We present the design and user evaluation of DIGEMERGO, a simulator for training and assessing emergency medicine management.Design approach: A prior Distributed Cognition in Teamwork (DiCoT) analysis of the Emergo Train System (ETS) guided the design process. The design objective of DIGEMERGO was to be useful, usable, retain distributed cognition features of ETS, and strengthen validity and output reliability.Evaluation: Eight expert ETS instructors participated in a formative system evaluation. The Technology Assessment Model (TAM) questionnaire was used to measure usefulness and ease of use. Observations and post-test interviews were conducted to contextualize the measures.Results: The results showed that DIGEMERGO was perceived as somewhat to quite useful and somewhat easy to use. Overall, expert users considered DIGEMERGO promising and successful in retaining core ETS features.Conclusions: The study indicates that a design methodology based on distributed cognition and simulation theory can be successfully combined to guide simulator (re)design and strengthen simulator validity.

Simulations are frequently used techniques for training, performance assessment, and prediction of future outcomes. In this thesis, the term "human-centered simulation" is used to refer to any simulation in which humans and human cognition are integral to the simulation's function and purpose (e.g., simulation-based training). A general problem for human-centered simulations is to capture the cognitive processes and activities of the target situation (i.e., the real world task) and recreate them accurately in the simulation. The prevalent view within the simulation research community is that cognition is internal, decontextualized computational processes of individuals. However, contemporary theories of cognition emphasize the importance of the external environment, use of tools, as well as social and cultural factors in cognitive practice. Consequently, there is a need for research on how such contemporary perspectives can be used to describe human-centered simulations, re-interpret theoretical constructs of such simulations, and direct how simulations should be modeled, designed, and evaluated.This thesis adopts distributed cognition as a framework for studying human-centered simulations. Training and assessment of emergency medical management in a Swedish context using the Emergo Train System (ETS) simulator was adopted as a case study. ETS simulations were studied and analyzed using the distributed cognition for teamwork (DiCoT) methodology with the goal of understanding, evaluating, and testing the validity of the ETS simulator. Moreover, to explore distributed cognition as a basis for simulator design, a digital re-design of ETS (DIGEMERGO) was developed based on the DiCoT analysis. The aim of the DIGEMERGO system was to retain core distributed cognitive features of ETS, to increase validity, outcome reliability, and to provide a digital platform for emergency medical studies. DIGEMERGO was evaluated in three separate studies; first, a usefulness, usability, and facevalidation study that involved subject-matter-experts; second, a comparative validation study using an expert-novice group comparison; and finally, a transfer of training study based on self-efficacy and management performance. Overall, the results showed that DIGEMERGO was perceived as a useful, immersive, and promising simulator -with mixed evidence for validity -that demonstrated increased general self-efficacy and management performance following simulation exercises.This thesis demonstrates that distributed cognition, using DiCoT, is a useful framework for understanding, designing and evaluating simulated environments. In addition, the thesis conceptualizes and re-interprets central constructs of human-centered simulation in terms of distributed cognition. In doing so, the thesis shows how distributed cognitive processes relate to validity, fidelity, functionality, and usefulness of human-centered simulations. This thesis thus provides a new understanding of human-centered simulations that is grounded in distributed cognition theor...

The results support the notion that the NASA TLX could be a useful complementary tool to evaluate exercise designs and outcomes. This should be further explored and verified in additional studies.