A Literature Study of Medical Simulations for Non-Technical Skills Training in Emergency Medicine: Twenty Years of Progress, an Integrated Research Framework, and Future Research Avenues

Medical simulations have led to extensive developments in emergency medicine. Apart from the growing number of applications and research efforts in patient safety, few studies have focused on modalities, research methods, and professions via a synthesis of simulation studies with a focus on non-technical skills training. Intersections between medical simulation, non-technical skills training, and emergency medicine merit a synthesis of progress over the first two decades of the 21st century. Drawing on research from the Web of Science Core Collection’s Science Citation Index Expanded and Social Science Citation Index editions, results showed that medical simulations were found to be effective, practical, and highly motivating. More importantly, simulation-based education should be a teaching approach, and many simulations are utilised to substitute high-risk, rare, and complex circumstances in technical or situational simulations. (1) Publications were grouped by specific categories of non-technical skills, teamwork, communication, diagnosis, resuscitation, airway management, anaesthesia, simulation, and medical education. (2) Although mixed-method and quantitative approaches were prominent during the time period, further exploration of qualitative data would greatly contribute to the interpretation of experience. (3) High-fidelity dummy was the most suitable instrument, but the tendency of simulators without explicitly stating the vendor selection calls for a standardised training process. The literature study concludes with a ring model as the integrated framework of presently known best practices and a broad range of underexplored research areas to be investigated in detail.


Introduction
Recent advances in the application of non-technical skills in emergency medicine have led to a growing interest in the use of medical simulations. The integration of medical simulations is an important step in the curriculum development process [1]. Although previous studies have examined simulation modelling in nearly all healthcare systems [2], few studies have adapted the definition of simulation to a fast-paced, team-oriented speciality. This article defines medical simulation in emergency medicine as the educational modality to provide participants with hands-on experiences in the diagnosis and treatment of acute illnesses such as trauma and injuries. Thus far, the area of application has almost entirely focused on eliminating disparities between theory and clinical practice. Realistic medical education uses a wide range of teaching techniques, such as dummies [3], mannequins [4], organs, film and television teaching materials [5,6], simulation cases [7], real patients or simulated patients [8], and so on. Although patient scenarios and conditions could be revised based on the instructor's choices, a realistic situation of doctors and nurses requires a methodical approach. Utilizing a variety of subspecialties, high-level digital simulation • Application paper. The study incorporates at least one medical simulation category and implements a simulation-based experiment to illustrate facets of emergency medicine. • Methodological contribution. The study precedes a simulation of any medical system; rather, it offers either a methodological critique or an evaluation of relevant simulation experiments. • Literature review. The study synthesises the significant aspects and outcomes from a vast number of references in the investigated area of research.
CiteSpace, an information visualisation tool for bibliometric analysis [26], is used to attribute publications by referencing networks. This presentation lines up scholarly patterns in scientific literature. The advancement of research avenues can be represented by sociogram-like clusters. These clusters consisted of nodes and link lines, respectively, denoting article data and co-occurrence relationships. The visualisation parameters are configured to prioritise significant referencing networks with the clearest labels: time slicing (from 2001 to 2020, years per slice = 1), node type (one selection at a time from keyword and institution), and pruning (none).

Results
Based on the SCI and SSCI literature, 298 out of 887 papers fulfil the inclusion criteria. Table 1 presents the categorization of 215 application papers, 50 methodological contributions, and 33 literature reviews, and published between 2001 and 2020. Of the entire selection, 161 records account for communication, 101 for teamwork, 68 for leadership, 47 for decision-making, 21 for coordination or collaboration, and 50 for other specific categories.

Medical Simulations for Non-Technical Skills Training in Emergency Medicine: Overview
In recent years, high-fidelity simulation has emerged as the most frequently deployed medical education instrument for enhancing the development of non-technical skills in emergency medicine. Their human-computer interaction interfaces bring together medical practitioners with convenience and fidelity. Among relevant publications, 69 records account for communication, 48 for teamwork, and 29 for leadership. The number of papers adopting mixed-method approaches and utilising observations outnumbers those records account for communication, 21 for teamwork, and six for leadership. It is worthwhile to note the prevalence of quantitative methods. Additionally, there is an equal number of studies performing simulations at the unit and department levels. Laerdal's SimMan products, however, remain the top choice. West et al. conducted interprofessional simulation activities using a disaster-day instrument [36]. The findings revealed higher students' self-ratings on average than those of the standardised patients. Couto et al. compared teamwork in emergency departments using video-based assessments [37]. On the basis of survey results, in situ simulation was considered more realistic and effective. To facilitate consistent safety measures during airborne rescue missions, Lischke et al. used MedSim to exercise communication, decision-making, and situational awareness [38]. Their pilot project introduced rich contextual information to the overview of the emergency scenario using terrain and helicopter wagons inside a mountain rescue training centre.

Communication
Communication plays an important role in developing therapeutic relationships between patients. The ability to build trust in the process of achieving common goals has become a highly sought-after non-technical skill in emergency medicine. It is often directly linked to the proficiency of both verbal and non-verbal responses. This management of challenging interactions between individuals is essential nowadays in the catchment area of emergency departments and medical workplaces. Joined by approximately 600 students at a U.S. dental school, McKenzie et al. studied the social determinants of health through simulation exercises on communication [45]. Results confirmed clinical performance improvement thanks to communication skills training with standardised patients and mannequins. Ayub et al. investigated the experience of prehospital providers in simulation settings [64]. The authors concluded that communication could overcome the environment-and manpower-related barriers, which have emerged as major themes in the delivery of patient-and family-centred care. Communication skill performance can be used to assess the educational effectiveness of medical simulators. To enhance acute care nurses' ability to identify and treat patient deterioration in a timely manner, Ozekcin et al. applied a non-technical skill framework in simulation exercises with debriefings [125]. Participants' responses showed a broadened knowledge base and decreased time span to critical actions once they adopted the situation, background, assessment, and recommendation strategies to recognise the instability of patients.

Teamwork
Teamwork skills in medical simulations are pursued in many innovative programmes to close performance gaps that impair practitioners' capacity. For teamwork training efforts to be successful, staff members must take part in the disclosure of urgent medical events and put forth a free flow of ideas across the emergency department. Teamwork could be exercised in simulation with overall improvements in team involvement, confidence, and objective understanding of the Emergency Airway Response Team, as suggested by Tsai et al.'s simulation project [210]. Knowledge assessment protocols might account for one's capacity to work in teams. Semler et al. analysed the effects of teamwork training with high-fidelity simulations, expert demonstrations of principles, and traditional didactics [73]. Expert-dependent, time-intensive simulation interventions offered positive effects on teamwork skills. Although individual skills improved as a result of simulations, according to Nelson et al. [217], the establishment of a positive atmosphere was not observed for the surgical wards. In addition to Nelson's suggestions for simulation-based training to raise awareness of safety issues, efficient teamwork was found to lower levels of patient harm in treatment [46]. Medical simulations combined with a structured teamwork curriculum could apply crew resource management principles to exemplify logistical considerations for acute stroke care.

Leadership
Leadership skills are increasingly recognised as strong determinants of peer relationships, workplace performance, and patient outcomes in emergency medicine. To promote a working environment steered by commitment, responsibility, and social order, leadership brings together personnel across disciplines to explore dynamic processes. In a simulationbased, randomised study, Weller et al. investigated information-sharing channels in an anaesthetic emergency [128]. The researchers discovered a link between information-probe sharing and callouts. A proactive team leader may expedite the development of a shared mental model among team members. Team debriefing immediately after resuscitation in simulation-based sessions contributed to declaiming leadership on-scene with the ambulance crew, as suggested by Clarke et al.'s study [213]. It was not just fulfilling a dedicated role for someone to stay with certain tasks; the resuscitation team leader rotated through the scenarios in Ten Eyck et al.'s study [12], suggesting that simulation training was critical to further developing strong leadership in comparison to the group discussion format. Lead-ership can also be exercised in the interpretation of training outcomes from crew resource management courses-Parsons et al. incorporated medical simulations into a residency curriculum endorsed by SimMan 3G [60], showing evidence of effective simulation in the clear instruction of non-technical skills.

Decision-Making
Following the literature study, decision-making skills in emergency medicine provide practitioners with the capacity to react quickly and swiftly. The decision-making process in medical simulations emerges as a powerful problem-solving mechanism. In Morreel et al.'s study, the authors proposed a guideline for practitioners to determine patients' triage urgency level in tandem with their present medical condition [183]. The simulation study confirmed the steps required for handling a telephone triage supported by the correct protocol, urgency category, and resource management. In addition, results showed acceptable performance of the decision support system. In Gerard et al.'s serious game study, participants acted as healthcare providers, assessing and treating a wide range of acutely ill patients [39]. Game scores can serve as valid indicators for assessing decision-making skills. In a randomised crossover study, Krage et al. identified declining non-technical performance once external stressors distracted individuals from routine tasks [120]. Their simulation study analysed the effects of stressful conditions on decision-making performance and technical skills training outcomes after a cardiopulmonary resuscitation scenario. Nicksa et al.'s interprofessional simulation simultaneously developed technical and nontechnical skills when dealing with high-risk situations [74]. The recreated scenarios were realistic and beneficial to the individual proficiency of surgical residents before handling such circumstances in reality. To summarise what has been stated so far, self-correction, monitoring, adherence to guidelines, and interactions between team members are critical to the decision-making process of high-stakes emergency scenarios in medical simulations.

Coordination and Collaboration
The interest in coordination and coordination corresponds to a greater awareness of patients under the system. This is based on a thorough understanding of cross-departmental and cross-institutional delivery systems. When handling tasks for patients, such nontechnical skills are warranted to offer appropriate recommendations. Abu-Sultaneh et al. used in-person simulations to activate collaboration within the regional hospital system [104]. The overall adherence to the critical action checklist increased to over 70% thanks to the quality management partnership. In a high-fidelity simulation study, Schumutz et al. explored the coordination of algorithm-driven and knowledge-driven implementations of emergency tasks [108]. It should be noted that coordination affected performance. Luctkar-Flude et al. evaluated the communication and interprofessional coordination skills of nursing and medical students after going through an asthma exacerbation simulation [83]. The design of medical simulation studies to practise interprofessional coordination skills was consistent with earlier research evaluating comfort levels and confidence with procedures.

Others
Situational awareness, resource management, resource utilization, prioritisation, and time management were recognised as the less frequently trained non-technical skills in the medical simulation of emergency medicine. Here, situational awareness refers to the application of the personnel's sensory systems to approach the working environment, bearing in mind anticipated threats and prospective consequences. Resource management addresses all logistical aspects of patient hand-off and transport. In light of this, resource utilisation emphasises the ability to reserve capacity in the occurrence of unexpected events. Prioritisation accounts for patient inflow mapping in which the most critically ill patients are given priority. Time management gives staff members back control over patients since emergency medicine would require simultaneous and sequential interventions performed by different personnel.

Scholarly Pattern Analysis
The literature study shows that approximately 50% of simulation studies conducted during the early years of publication featured only one type of skill. To date, this accounts for the greatest proportion across medical simulation categories. In contrast, only in 2008 and 2015 did the number of simulation studies involving two types of skills outnumber those of all other categories. As the number of simulation studies involving more than two types of skills has increased recently, this trend has been applied throughout the graph, as shown in Figure 1. After reaching 33% in 2018, the percentage of research requiring more than three types of skills decreased, with the lowest gap between the categories occurring in 2019. In 2020, more scholarly attention was devoted to simulation studies of only one type of skill and two types of skills.
events. Prioritisation accounts for patient inflow mapping in which the most critically patients are given priority. Time management gives staff members back control ov patients since emergency medicine would require simultaneous and sequent interventions performed by different personnel.

Scholarly Pattern Analysis
The literature study shows that approximately 50% of simulation studies conducte during the early years of publication featured only one type of skill. To date, this accoun for the greatest proportion across medical simulation categories. In contrast, only in 20 and 2015 did the number of simulation studies involving two types of skills outnumb those of all other categories. As the number of simulation studies involving more than tw types of skills has increased recently, this trend has been applied throughout the grap as shown in Figure 1. After reaching 33% in 2018, the percentage of research requirin more than three types of skills decreased, with the lowest gap between the categories o curring in 2019. In 2020, more scholarly attention was devoted to simulation studies only one type of skill and two types of skills.  The bar chart indicates that simulation studies involving only one profession were distributed across the time period ( Figure 2). While some researchers attested to the competency of two professions, others researched three or more. Overall, research involving only one profession had the largest number of publications, whereas there were few studies that did not explicitly state any profession. Those involving two professions and more than two professions had 59 and 76 publications, respectively. Notably, these categories have similar profiles. The frequency of publications involving only one profession grew substantially between 2001 and 2009. It fell somewhat between 2009 and 2010. Following that, the number of publications increased until it peaked at 12 in 2015. Its proportion, however, fell dramatically during the next five years.
Observations were the most common source of behavioural data during the time period, as shown in Figure 3. Between 2001 and 2010, the majority of research recognised video and verbal references among participants. In addition, built-in analysers have become more popular in screen-based and human-patient simulations. This was a promising source of behavioural data, whether quantitative or qualitative, as it provided a better understanding of the levels at which participants engaged the most. Simulation studies combining observational data and analysis procedures have contributed to a large proportion of publications between 2015 and 2020. However, in the last five years, studies that did not rely on any specific data sources have become more common. There is a need to take advantage of actionable intelligence in order to describe the psychological profiles of participants. Observations were the most common source of behavioural data during the time p riod, as shown in Figure 3. Between 2001 and 2010, the majority of research recognis video and verbal references among participants. In addition, built-in analysers have b come more popular in screen-based and human-patient simulations. This was a prom ing source of behavioural data, whether quantitative or qualitative, as it provided a bett understanding of the levels at which participants engaged the most. Simulation studi combining observational data and analysis procedures have contributed to a large pr portion of publications between 2015 and 2020. However, in the last five years, studi that did not rely on any specific data sources have become more common. There is a ne to take advantage of actionable intelligence in order to describe the psychological profil of participants. As seen in Figure 4, the literature study identifies the operational clinical enviro ment at the unit, department, and institution levels. The majority of research in this sect has been unit-wide, carefully monitoring the health status of patients. The data revea  Observations were the most common source of behavioural data during the time p riod, as shown in Figure 3. Between 2001 and 2010, the majority of research recognise video and verbal references among participants. In addition, built-in analysers have b come more popular in screen-based and human-patient simulations. This was a prom ing source of behavioural data, whether quantitative or qualitative, as it provided a bett understanding of the levels at which participants engaged the most. Simulation studi combining observational data and analysis procedures have contributed to a large pr portion of publications between 2015 and 2020. However, in the last five years, studi that did not rely on any specific data sources have become more common. There is a ne to take advantage of actionable intelligence in order to describe the psychological profil of participants. As seen in Figure 4, the literature study identifies the operational clinical enviro ment at the unit, department, and institution levels. The majority of research in this sect has been unit-wide, carefully monitoring the health status of patients. The data revea that 2009 was the year with the highest number of unit-wide simulation studies, follow by a gradual increase in the number of publications addressing non-technical skill issu As seen in Figure 4, the literature study identifies the operational clinical environment at the unit, department, and institution levels. The majority of research in this sector has been unit-wide, carefully monitoring the health status of patients. The data reveals that 2009 was the year with the highest number of unit-wide simulation studies, followed by a gradual increase in the number of publications addressing non-technical skill issues at the institutional level. Prior to 2011, there was department-wide training, with a steady growth in publications from 2017 to 2020. It is important to note that a number of studies have not explicitly stated the level of the operational clinical environment.      at the institutional level. Prior to 2011, there was department-wide training, with a stead growth in publications from 2017 to 2020. It is important to note that a number of studi have not explicitly stated the level of the operational clinical environment.

Bibliometric Analysis
As shown in Figure 6, the citation networks of articles are formed by keywords such as simulation (155), medical education (106), teamwork (52), anaesthesia (28), non-technical skill (26), airway (25), cardiopulmonary resuscitation (21), and diagnosis (2). Remarkably, each network contains publications throughout the course of the time period. Simulation, the keyword from the core thematic trend, leads to technology, education, anaesthesia, error management, emergency, and preparedness-this is an example of how the central citation network has extended to spearheading research areas. Through research efforts on educational technology, communication, and cultural value, articles on teamwork have covered both the technological and social aspects. Up to this point, these networks have had a lower concentration. In contrast, medical education develops a more complex cluster despite being referenced less often. The second-largest cluster publishes articles in certain areas, such as high-fidelity simulation, management skills, guidelines, and resuscitation. This pattern also applies to other clusters with smaller numbers of publications. Anaesthesia is an important subcategory of study that led to the research fields of crisis resource management and safety. Similarly, non-technical skills, connected by clinical performance, assessment, and checklists, proceed to cognitive aid. Airways and diagnosis have created new research revenues in clusters away from their central counterparts, indicating a broader scale of medical simulations. As shown in Figure 6, the citation networks of articles are formed by keywords such as simulation (155), medical education (106), teamwork (52), anaesthesia (28), non-technical skill (26), airway (25), cardiopulmonary resuscitation (21), and diagnosis (2). Remarkably, each network contains publications throughout the course of the time period. Simulation, the keyword from the core thematic trend, leads to technology, education, anaesthesia, error management, emergency, and preparedness-this is an example of how the central citation network has extended to spearheading research areas. Through research efforts on educational technology, communication, and cultural value, articles on teamwork have covered both the technological and social aspects. Up to this point, these networks have had a lower concentration. In contrast, medical education develops a more complex cluster despite being referenced less often. The second-largest cluster publishes articles in certain areas, such as high-fidelity simulation, management skills, guidelines, and resuscitation. This pattern also applies to other clusters with smaller numbers of publications. Anaesthesia is an important subcategory of study that led to the research fields of crisis resource management and safety. Similarly, non-technical skills, connected by clinical performance, assessment, and checklists, proceed to cognitive aid. Airways and diagnosis have created new research revenues in clusters away from their central counterparts, indicating a broader scale of medical simulations.    To summarise what has been stated so far, remarkable collaboration networks are gathered through universities, hospitals, and labs in North America.
University are the most frequently collaborating partners in research activities. P larly, several renowned institutions serving as guiding hands-the Medical Sim Centre, Columbia University, and Case Western Reserve University-have contrib high-level research collaborations as part of a thriving international community ever, growing networks joined by European affiliations have recently piqued rese terests. To summarise what has been stated so far, remarkable collaboration netwo gathered through universities, hospitals, and labs in North America.  Figure 8 presents the timeline view of the CiteSpace map. The solid lines den matic horizons such as computer simulation, outcome, quality improvement, tria tient safety, impact, randomised controlled trials, group decision-making, anap and management games, covering methodological and application-oriented persp In addition, a group of phrases are identified as keywords to illustrate how the changed over time. It is worthwhile to note that triage, impact, and randomised con trials exist throughout the time period. Prior to 2010, a preponderance of new id approaches was created, as seen by the graph. The treatment of critically ill patien anaphylaxis was inspired by the intersection of computer simulation and resusc Simulation in the management game's thematic horizon continues with medical c teamwork. Last but not least, later in the timeline, there are keywords such as "co aids," "tools," "patients," and "programmes" on patient safety, triage, and compu ulation.  Figure 8 presents the timeline view of the CiteSpace map. The solid lines denote thematic horizons such as computer simulation, outcome, quality improvement, triage, patient safety, impact, randomised controlled trials, group decision-making, anaphylaxis, and management games, covering methodological and application-oriented perspectives. In addition, a group of phrases are identified as keywords to illustrate how they have changed over time. It is worthwhile to note that triage, impact, and randomised controlled trials exist throughout the time period. Prior to 2010, a preponderance of new ideas and approaches was created, as seen by the graph. The treatment of critically ill patients with anaphylaxis was inspired by the intersection of computer simulation and resuscitation. Simulation in the management game's thematic horizon continues with medical care and teamwork. Last but not least, later in the timeline, there are keywords such as "cognitive aids," "tools," "patients," and "programmes" on patient safety, triage, and computer simulation.

Ring Model
The literature study discovers no theoretical frameworks to synthesise previous research findings. To shed light on the linkages between medical simulations and experience design, which are promising to fertilise innovative ideas in both directions, this study presents a ring model as an integrated research framework (Figure 9). Amongst other things, debriefing is recognised as the main component to safeguard intended training goals, eliminate contextual limitations, and facilitate medical knowledge transfer to real working environments. It might be challenging to raise adjustments at each stage of the medical simulation study while also undergoing all stages of the ring model. However, these steps are necessary to concretise training outcomes in emergency medicine. In a nutshell, a medical simulation project is administered on the basis of all the design considerations for functionally driven and effectively organised non-technical skills training activities.

Ring Model
The literature study discovers no theoretical frameworks to synthesise previous research findings. To shed light on the linkages between medical simulations and experience design, which are promising to fertilise innovative ideas in both directions, this study presents a ring model as an integrated research framework (Figure 9). Amongst other things, debriefing is recognised as the main component to safeguard intended training goals, eliminate contextual limitations, and facilitate medical knowledge transfer to real working environments. It might be challenging to raise adjustments at each stage of the medical simulation study while also undergoing all stages of the ring model. However, these steps are necessary to concretise training outcomes in emergency medicine. In a nutshell, a medical simulation project is administered on the basis of all the design considerations for functionally driven and effectively organised non-technical skills training activities. The diagram shows the five stages of instruction that are given to the participants. According to prior studies, realism in the initial stage directly links to the description of patient flows, resources, and accountability frameworks. Participants engage in medical simulations only if they receive a sense of authenticity from the constructs, value sharing, and inspirations between team members. Simulation methods include simulators, simulated patients, Virtual Reality, and Augmented Reality, depending on the learning outcomes and objectives. Amongst other things, simulated patients are ideal for teaching communication, conflict management, compassion, and ethical dilemmas, whereas human simulators may be used to build therapeutic resilience. At this point, it is worthwhile to justify the application of simulation in terms of medical benefits, emotional interests, The diagram shows the five stages of instruction that are given to the participants. According to prior studies, realism in the initial stage directly links to the description of patient flows, resources, and accountability frameworks. Participants engage in medical simulations only if they receive a sense of authenticity from the constructs, value sharing, and inspirations between team members. Simulation methods include simulators, simulated patients, Virtual Reality, and Augmented Reality, depending on the learning outcomes and objectives. Amongst other things, simulated patients are ideal for teaching communication, conflict management, compassion, and ethical dilemmas, whereas human simulators may be used to build therapeutic resilience. At this point, it is worthwhile to justify the application of simulation in terms of medical benefits, emotional interests, and self-expression. In light of this, data collection refers to gathering patient flow data, in accordance with the ethical agreement, to populate the simulation model. This is necessary to represent complicated and difficult cases. In the following stages, interprofessional teams are prepared for emergencies in a simulated setting. This is accomplished through mastering non-technical skills. Next, a data analysis is conducted using predetermined measures for patient outcomes, protocol adherence, behavioural retention, and healthcare logistics. The debriefing stage involves thought-provoking discussions in an iterative and retrospective process where team members learned from each other and from themselves.
If manipulators are employed, computer-assisted instruction has to be taken into account. The presence of engineers is also required. It is necessary to promptly and sensibly alter the physiological value in the teaching plan in response to the participants' performance as per the real circumstances in the classroom. The instructor may utilise role-playing approaches to teach empathy or ethical issues. By role-playing, after-views and debriefing, this ring model could accommodate the learning process.
The debriefing stage involves thought-provoking discussions in an iterative and retrospective process where team members learned from each other and from themselves. Various debriefing provisions might be subject to concerns that interruptions disturb fidelity and adversely affect learning. The author suggests a rigorous comparison of debriefing strategies with medical simulations to explore the effects on non-technical skills acquisition and learning experience.

Discussion
This section describes the high-yield topics for future research. The answers to these research questions will inform medical simulation instructors on how to appropriately organize training content and handle design issues.

Practice-Based Training and Improvement
The context brought to interprofessional situations can influence the degree of contact and the pace of training. It is vital to have an overview of each team member's skills and interests in order to respect altruism, culture, age, and gender. When aligning intended training goals, the first aspect that can be noted by instructors is their impact on the personnel undertaking interprofessional responsibility in medical simulations. A difference was made between the distribution of responsibilities among team members and the knowledge exchanges, according to MacNaughtonet et al.'s study [316]. In addition to the fundamentals of the medical system, participants need a comprehensive understanding of the activities and necessary skills to deliver excellent patient outcomes as the situation deteriorates. Even though patient scenarios could be supplied with task trainers [317], increasing the use of simulation in emergency medicine should allow the integration of skills that not only strives for professionalism but also clarify accountability frameworks in a dynamic process.
Although delivering quality and safe care within the purview of a single institution is of primary concern, it is also encouraged for networked medical institutions to approach more complex issues with interdependent threads. The majority of research has focused on non-technical skills training in a clinical environment with limited operational capacity. Nevertheless, multi-centred simulation initiatives have been conducted in an effort to establish stronger cross-institutional partnerships [46,103]. The delivery of training experiences is on the rise to promote the innovative use of information technology with a focus on system solutions. Instructors may now elicit hitherto splendid and overlapping processes into complete medical procedures and patient management plans. In addition, cross-institutional comparisons of training results may be undertaken to analyse the areas that need to be improved in individual practice projects. This study posits the following question to be answered in future simulation projects: • 'How can various agencies be brought together via simulation-based non-technical skills training?' • 'How can medical simulations foster innovative strategies for addressing challenges that cannot be resolved independently?'

Teaching Theories and Educational Planning Models
Seldom did authors address teaching theories and educational planning models. However, it is becoming more essential to figure out how individuals receive, process, and retain information throughout learning. Kolb's Learning Cycle [318], also known as the Experiential Learning Cycle, could serve as the cornerstone for a learning-by-doing paradigm. According to the framework that is primarily used in nursing education [319], concrete experience, reflective observation, abstract conceptualization, and active experimentation are the four stages that must be completed for successful learning. Also, further study may broaden educational planning models for the development of practical courses. One such template could be Kern's six-step approach to clarify the intended learning outcomes of the overall programme and of individual sessions [320,321]. In such cases, the effective blending of the experience of learners together and instructional design is a keyword. The following research question should help researchers in the pursuit of a leaner-centred style: • 'How do we apply teaching theories and major approaches to educational planning with medical simulations for non-technical skills training in emergency medicine?'

Medical Simulation Verification and Validation
Although certification in medical simulations is becoming more of a priority to identify best practices for a wide range of providers and applications [322], the credibility of medical simulation models remains largely underexplored. Barnes and Konia confirmed many different interpretations and accomplishments in healthcare simulation studies [323]. For example, Abir et al. developed a discrete-event simulation model to predict capacity bottlenecks at a medical centre [176], allowing for improved decision-making with changes in the working environment. However, rarely have such reviews been conducted in medical simulations-the majority of articles recreated tasks, cases, and scenarios rather than closely examining logistical aspects of emergency medicine. Most medical simulation studies currently lack an iterative model-building procedure. This warrants validation and verification throughout the operational requirements. The following research questions are outlined in order to ensure an accurate description of the medical system:

•
'What paradigms should be developed for verifying and validating medical simulations in emergency medicine?' • 'How can instructors describe the logistical aspects of emergency medicine using real-time clinical data and patient inflow patterns?'

Applied Ergonomics
Medical equipment and apparatus used with simulators should take ergonomics and human factor engineering into account. However, the literature study reveals inadequate attempts to reduce fatigue, discomfort, and injury. Such aspects of applied ergonomics may be enhanced to reduce participant risk and better-fit training processes. This is a promising research domain since medical equipment must frequently be manoeuvred quickly and safely in different simulated scenarios.
Repeated exposure to high-fidelity simulations has turned out to be an effective teaching strategy [324]. It was shown that early exposure to a complex clinical environment was helpful for transitioning knowledge into practice [325]. Nevertheless, prior research has not demonstrated a correlation between repeated exposures and an increase in participant stress levels [326]. When the participant takes a considerable amount of experience in simulations, the relationship between the quantity of practice, the acquisition of non-technical skills, and the impact on the sense of well-being should be elucidated from an ergonomic perspective.
Aside from quantitative research analysing the distributions of cognitive stress, it is promising for qualitative studies of focus groups to look for patterns or themes across entire datasets. Furthermore, mixed-method studies may help with data interpretation and broaden the generalizability. Therefore, it is worthwhile to answer the following question: • 'How could technology-driven tools as user-centric design approaches overcome ergonomic issues with medical simulations?'

User Interface Design
In contrast to interactions with a conventional graphical user interface, which mostly involve using a mouse and keyboard, the next step in the evolution of user interfaces will make user interaction appear enjoyable, motivating, and intuitive. Researchers attempted scoring systems to measure multitasking skills in an emergency department [327] and address logistical bottlenecks in paediatric emergency medicine [328]. However, the literature study identifies only a few simulation projects that touched upon design issues. Due to a dearth of in-depth studies on user engagement and adoption, there is a lack of understanding of the expected actions from digital features. Designers should embrace such elements to improve the timeliness of task completion, reduce omissions, and pinpoint aspects of the user experience.
The user interface design will serve as a key component of next-generation simulators. This tendency requires the optimum usability, performance, and manoeuvrability of the digital media objectives. To date, the design patterns used in medical simulations have not been elucidated. Not only can user interface elements behave in specific ways, but there are also visual aesthetics, inclusion, and the adoption of habit-forming technologies, all of which contribute to a higher level of authenticity. Despite these promises, the interface needs to be suitable for medical system integration [329]. Given the lack of a detailed examination of user interface design, the following research question needs to be investigated:

•
'What is the cutting-edge innovation in interface design for the integration of function and usability?'

Conclusions
This literature study presents a synthesis of previous simulation projects that explicitly trained non-technical skills in emergency medicine. Over the decades, advances in a wide range of medical simulation categories have been made using scientific research evidence and statistical methods. These contributions addressed the intersections between medical simulations, non-technical skills training, and emergency medicine. In addition, the literature study reveals a substantial body of evidence-based practice that improves the design of training experiences for communication, teamwork, leadership, coordination, and decision-making. The presence of patient cases and the involvement of professionals showcase how the prior research design could be extended to more detailed patient scenarios. More importantly, simulation-based education should be considered as a teaching approach to substitute high-risk, rare, and complex situations in technical or situational simulations. In light of this, the ring model as an integrated framework is proposed for conceptualising the innovative design method-it aims for the transfer of simulation-based training outcomes to a real working environment.
It has been over two decades since the publication of the landmark report 'To Err Is Human: Building a Safer Health System' [330]. The growing awareness of medical mistakes is steering interest in teaching not just technical but also non-technical skills, an area of study that has received relatively little attention in general and in emergency medicine in particular. The medical system should be rethought as a social-technical system with processes and interactions across the medical pathways.
The literature study is subject to limitations. First of all, to avoid overlooking significant practice-based evidence, the search terms should combine keywords pertaining to the less often trained non-technical skills and more specifically employed research methods, respectively. In addition, despite using entries from the Web of Science Core Collection editions, the electronic data search may not be exhaustive. The omission of abstracts, conference proceedings, posters, and book reviews might lead to a selection bias in publications. Furthermore, the research only traced papers published after 2000. Attention to earlier articles may aid researchers in explaining the current status of the topic and pointing out a number of changes in the way the field is pioneered. In order to dive into the specifics, a previously proven methodology for profiling key variables in healthcare simulations [331], explored by earlier researchers, would benefit from visualising the design of queries, the use of search tools, and the evaluation of each article. Further literature studies shall reflect on lessons learned from the gradual shift towards competency-based medical education over the past decades, the meaningful presence of milestones and entrustable professional activities in medical behaviour [332], and how simulations in general have built surrounding heuristics into medical education.
Since the literature study is pioneering in this area, a synthesis of the outcomes over the past two decades outlines a broad array of research questions on the implementation of medical simulations in general and non-technical skills training in emergency medicine in particular. The need to capitalise on the characteristics of medical simulations warrants further investigations on practical training, validation and verification of medical simulations, user interface design, and applied ergonomics. These reflections on emerging research avenues should contribute to the body of knowledge on these underexplored areas. It is anticipated that future research will continue to deliver user-centric training experiences but will undertake an innovative design approach dedicated to the pursuit of performance excellence in simulated settings and longer retention of skills after completing the assignment. Last but not least, from a methodological standpoint, more qualitative studies should be carried out to streamline discourses from verbal, written, or language-use materials. Particularly, the application of thematic and content analysis, which has been largely unexplored in prior research, will help close the knowledge gap in the achievement of training goals and the provision of training experiences.
Funding: This work was supported by the Research Foundation for Youth Scholars of Beijing Technology and Business University. Data Availability Statement: Data used to support the findings of this study are available from the corresponding author upon request.

Conflicts of Interest:
The author declares no conflict of interest.