Family presence during resuscitation (FPDR) refers to the practice of allowing family members or loved ones to be present in the room while healthcare providers are performing life-saving procedures, such as cardiopulmonary resuscitation (CPR) [1]. FPDR is ethically recommended for promoting shared decision-making and respecting family autonomy [2]. Managing FPDR requires physicians to have not only knowledge and skills related to resuscitation, but also non-technical skills, such as communication with family members, which are equally crucial. Healthcare professionals tasked with FPDR responsibilities must implement effective practices accordingly. In this regard, learning outcomes of FPDR resident simulation programs have emphasized the development of non-technical skills like teamwork, crisis management, and strategies for involving families in resuscitation without compromising the quality of CPR [3]. However, simulation-based education focusing on FPDR is more common for nurses than for physicians, and even less so for medical students [4].

It is noteworthy that FPDR requires healthcare providers to communicate with the family based on cultural humility, especially if the culture and linguistic contexts of the patient and their family differ from those of healthcare providers. Cultural competence in healthcare combines the tenets of patient/family-centered care with an understanding of the sociocultural influences that affect the quality of medical services and treatment [5]. Englander et al. [6] report that patient or family communication is a general physician competency that specifically focuses on cultural diversity. Interestingly, FPDR typifies an occasion to attend to the cultural background of patients and families and to learn to navigate the impact of cultural differences in resuscitation situations.

However, previous studies on CPR quality in FPDR scenarios lack detailed information regarding the design and facilitation of such simulation scenarios [7,8]. Herein, we aim to develop a scenario for medical students that incorporates cultural diversity within the FPDR context, gather data from this pilot study to refine the program, and share our experiences.

This is a case-based scenario that uses hybrid simulation with a high-tech patient mannequin and an embedded family member participant. It was designed by a Korean emergency physician (K.H.P.) during a postgraduate simulation fellowship at the SimTiki Simulation Center in Hawaii, United States. The protocol was reviewed by the University of Hawaii Human Studies Program and determined to be a non-human-subject research, with an exemption from the formal review. Video and audio recordings of the simulation and debriefing were collected in accordance with policies in which all users of the center acknowledged that video/audio recordings could be used for research and education purposes.

Two male medical students born and educated in the United States participated in the simulation: one identifying as local Japanese and the other as Japanese-American. They stated that this simulation differed from previous ones because it focused on learning to communicate with the patient’s family rather than diagnosing or treating the patient’s condition. They were familiar with the concepts of cultural competence, and, uniquely, during this scenario, they were able to implement such concepts. They previously felt that FPDR would distract them from good CPR care and stated that being honest with the family and asking how the family would like to communicate would be lessons learned from this scenario for application in future real-life situations. They plan to ask patients’ families how much information they want disclosed and encourage them to participate in medical decisions.

Strategies for improving the scenario emerged from faculty discussions. First, strong forcing functions and transitions should be incorporated to ensure that both students have the opportunity to communicate with the family, or that the same scenario should be repeated to allow all students to experience family interaction. Before the pilot test, it was expected that two student participants would allow for sufficient spontaneous communication experience for both. However, during the pilot test, one student primarily communicated with family. Second, the timeline needed acceleration to be completed within the allocated 10 minutes. Leg massage began at the third minute of the scenario, and the students did not directly convey the patient’s death to the wife; therefore, the family could not request continued CPR until the son arrived. A design modification for immediate leg massage as the scenario begins addressed this issue. Adding a defibrillation requirement would promote students’ awareness of the wife’s leg-massaging behavior without cues from the nurse facilitator. Third, a dedicated, standardized, and embedded participant family member is required. In this pilot study, one researcher (B.W.B.) observed the simulation and managed the debriefing. If such an observer is not available, either the standardized participant or the nurse facilitator will need to debrief. While actively participating in and facilitating the simulation, they may be unable to accurately observe the learners’ performance. Therefore, the wife should be replaced by a standardized participant, and a nonparticipating faculty should conduct the debriefing.

In this pilot, a simulation scenario was developed for medical students to learn about cultural competencies during FPDR. Learners stated that they were aware of the concept of cultural competency, and this scenario allowed them to understand its practical implementation. Moore et al. [10] reported that nursing students expressed a desire for simulation programs related to diversity, equity, and inclusion (DEI) to be more accurate and specific regarding cultural concepts such as diverse family structures and different health beliefs. In this scenario, medical students of Japanese cultural background from the United States experienced Korean family culture while communicating with a family member. This represents a relevant situation in many countries comprising people from diverse cultures.

There is a lack of research on cultural diversity or competency in Korean medical education. In Korea, the population from other cultures and foreign countries is increasing, same as the number of patients from other cultures visiting to receive medical care [11,12]. The cultural competencies of healthcare professionals, including physicians, ultimately affect patient-centered care. Roh and Nirta [13] conducted a class that allowed medical students to reflect on cultural diversity through panel discussion. This pilot program demonstrates the feasibility of a learning experience in which cultural diversity is represented and learners can apply cultural competencies in a clinical setting. Content that allows for the learning and application of DEI concepts, including cultural competency, must be considered in the Korean medical education curriculum.

This pilot study has a few limitations owing to being a single program evaluation. Based on the data analyzed herein, it would be feasible to implement an FPDR simulation program that can be repeated with multiple medical students. Furthermore, this scenario could be used for CPR simulation in other contexts where communication with patients or family members from diverse cultural backgrounds is a key learning objective.