Malnutrition has important health impacts, especially in the elderly. Oral nutritional supplements (ONS) are effective strategies to help balance the nutritional needs of malnourished persons. Multiple ONS are available at community pharmacies, enabling pharmacists to have the possibility to implement strategies for prevention and monitoring of malnourished patients. The aim of this study was to characterize the experience of community pharmacists with the counseling and follow-up of users of ONS. A sample of 19 pharmacists from 19 different community pharmacies were interviewed. Apart from dispensing ONS to support patients that are preparing for diagnostic tests, the most frequently mentioned clinical condition for ONS counseling was malnutrition and dysphagia. When pharmacists consider dispensing ONS, three themes emerge: patient care, related to counselling tailored ONS to each patient’s needs; interprofessional collaboration, with a special focus in the collaboration with registered dietitians; and training and education on ONS, looking to improve their knowledge and skills in ONS counselling and follow-up. Future studies exploring new forms of interaction between pharmacists and dietitians in this context should be developed, aiming to determine the workflow of an interdisciplinary service addressing the needs of community dwelling malnourished patients. Malnutrition, a common process in the elderly and in cancer patients, which results from a lack of nutrient intake or absorption, leads to changes in body composition and impaired clinical outcomes ,2,3. OneONS are homogeneous mixtures of nutrients balanced for higher caloric intake, classified as food for special medical purposes to control disease-related malnutrition, that are commercially available for oral administration . AdminisNutritional interventions, consisting of dietary advice alone or in combination with an ONS, are considered an important cornerstone in the treatment of disease-related malnutrition . ONS prePortugal is currently one of the few countries where registered dietitians can carry out nutrition consultations in community pharmacies . The intGiven the novelty of the topic in this specific practice setting, an exploratory qualitative approach is the preferred methodology. In fact, there is little research on the use of ONS in community pharmacy, although some evidence already exists on the role of primary health care in the management of malnutrition in the community ,20.To implement this qualitative approach, a desk review on the topic was previously carried out aiming to screen the literature to understand the current state of the art and to understand which dimensions of pharmacists’ activity would be under investigation. PUBMED was searched, using Boolean operators to combine terms, such as “malnutrition”, “interventions”, “primary care”, “community pharmacists”, “dietitians” and “oral nutritional supplements”. This initial review informed the design of an initial interview script, consisting of 27 questions, which was pilot tested with three community pharmacists. After this pilot, three questions were changed and four questions withdrawn, resulting in the final version to be used . The population of interest were community pharmacists of the district of Lisbon, Portugal. The sampling was conducted according to the snowball sampling method, i.e., the selection of the subjects that make up the sample is made through nominations suggested by the respondents . As inclThe interviews took place during May and June 2021, over Zoom© videoconferencing platform  . Zoom© i® spreadsheet. Afterwards, another researcher (JG) independently reviewed all the transcripts and produced more codes and themes. Finally, the themes were reviewed and discussed by all authors, until a set of final themes was identified. Descriptive statistics of the quantitative data collected  were also performed. The study protocol was submitted and approved by the Institutional Ethics Committee of Universidade Lusófona de Lisboa (CE. ECTS/P06-22).The audio recordings of the interviews were transcribed verbatim by the interviewer (PT) immediately after the interview, limiting memory bias. Preliminary thematic analysis of the transcriptions was performed by one researcher (PT), organizing the transcriptions and initial themes into an MS ExcelNineteen pharmacists were interviewed, eighteen female and one male. Participants’ ages ranged from 25 to 43 years old, with an average of 32 years old . The meaThree quarters of the pharmacists said that the pharmacy where they work has nutrition consultations, all of them performed by registered dietitians. In these pharmacies, 38% of the consultations were exclusively focused on weight loss, while the remaining addressed other topics, such as clinical nutrition, body mass increase, dietary guidance for vegetarians and breastfeeding. Regarding the frequency of ONS counseling, it ranged from daily to monthly, with 42% of pharmacists stating that they provide counseling on ONS at least once a week. All respondents said that their pharmacy had ONS for sale, even in those pharmacies who did not have a nutrition consultation. Pharmacists stated a wide variety of reasons to counsel or sell these ONS .As expected, the main reasons to counsel ONS were directly related to their clinical indications. As for the information provided in this counseling, all pharmacists declared advising on the daily intake and time of administration. Only half informed about the storage precautions and need of refrigeration, and only two would give information on the duration of the therapy.When counseling an ONS, pharmacists worried about specific pathologies or clinical situations that may impact their counselling protocol. The most frequently mentioned clinical condition to be considered during the ONS counseling was diabetes (84%), followed by renal insufficiency (47%) and oncological/cancer problems (37%). Dysphagia (26%) and swallowing problems, malnutrition, and bedridden patients (16%) were also mentioned. Other pathologies that deserve pharmacists’ attention when counselling ONS were liver failure, pressure ulcers or bedsores, patients who are tube fed, patients with neurological diseases (Alzheimer’s and Parkinson’s) and polymedicated patients. From our data analysis, three main themes related to the role of pharmacists in counselling ONS emerged: how and why to counsel and follow-up ONS consumers; ONS consumers follow-up as an interprofessional collaboration; and pharmacists’ training and education needs about ONS. In the following sections details are provided to each of these themes.After counselling an ONS, all respondents considered it important to monitor patients on ONS, mainly to assess its evolution but also to increase personal trust in the product they were counseling or to increase customer loyalty to the pharmacy. The feedback given by the patient/client after the sale allows an increase in confidence in the product and in the advice given.“Yes, I think it’s important, even to know if it’s working, if the patient is improving. In this way you also gain more confidence for new counseling. It is always an added value for us pharmacists to know if it is working or not, if it works it means that the supplement is effective and that the person is improving, which allows us to also have more confidence in the product and advise it more often.” 3ED, F, age 33.Confidence in the product and in their own professional abilities seems to play an important role when counselling an ONS. This is most evident with cancer patients, where pharmacists considered that it is safer for this type of patient to have a medical prescription before coming to the pharmacy, thus also facilitating the counseling and follow-up of the patient. They were unanimous in recommending that this type of ONS be taken as directed by the product itself:“Oncology patients and dietary supplements…. I don’t usually counsel. I always ask to talk to the doctor first, because with cancer patients, I don’t know what kind of treatments they are doing and although there are these kinds of supplements not all supplements are suitable for oncology. (…) I’m always very afraid.” 11JO, F, age 27.As for how to perform patient monitoring, most pharmacists said they assess the patients when they return to the pharmacy. Only two pharmacists said they assess proactively . Two pharmacists indicated that they did not consider follow-up necessary, or if it is necessary, the registered dietitians should provide it:“I think it’s important, and we follow up on this by waiting for the patient to return to the pharmacy (…) and we then ask “so how are you doing?”, as a way of understanding if everything is going well or not.”2MÇ, F, age 30.“(…) we know people relatively well, and when we leave the pharmacy and walk around in the street, we also meet them and we also ask how they are, if there are results, if they are feeling well (…).” 9AA, F, age 28.Most of the pharmacists interviewed considered themselves to be the main facilitator for patient follow-up, possibly recording follow-up information in a dedicated information system. Another important facilitator for patient follow-up was the existence of a specific consultation for these patients. Lack of time was referred to as one of the barriers, while two pharmacists considered that, since the pharmacy is located in a small neighborhood, where the relationship with the patients is closer, the registration of information was not needed:“It could be important to have the information registered, but it would be more complicated, it would already be too much, in my opinion. But the time factor is important. I would love to have time to keep up with everyone, but this in an ideal point of view and it’s not realistic.” 5RI, F, age 27.The majority of the respondents (53%) pointed to the high cost of ONS as the main barrier to adherence, which in turn contributes to lower counseling and sales opportunities. Also hindering counseling is the lack of knowledge regarding several ONS characteristics, such as dosage, duration of therapy and possible adverse effects in special cases, such as children, pregnant women, polymedicated patients and intolerances. The range of offers also makes it difficult to choose the ONS most adapted to the individual patient’s needs:“The price of this type of supplement is very high, which sometimes makes adherence to this type of therapy more difficult, especially for the elderly, who usually spend a lot of money on medications. Taking into account that these supplements can be an important help in the improvement and well-being of these people there should be an aid to support these costs, or even be reimbursed, given its relevance in the health of the user.” 3ED, F, age 33.“We can sometimes advise to replace a meal, but people end up not adhering to it because the costs are so high.” 8AG, F, 25 years old.Two other health professionals were referred to as having an important role in ONS prescription, counselling, and follow-up: physicians  or specialists) and registered dietitians. Physicians were usually evoked to deal with difficult cases, such as cancer patients, while dietitians were mostly recognized as a useful ally in both patient counselling and follow-up, using the experience of nutrition consultations as a benchmark:“In that case [cancer patients], we always try to have that kind of counseling done more by the doctor than by us, for safety’s sake, because they are more fragile patients with certain specific needs (…). We advise them, we let them know what is available and what the benefits are, but we say that the best thing is to talk to the doctor (…) so that we don’t take risks with this type of patient, because they are a type of patient that needs other care. If it comes with a doctor’s indication we advise the basic care to have.” 8AG, F, age 25.“Just as there is the nutrition consultation, there could be a follow-up consultation with the patient, according to his/her needs, making a record of his/her condition, if he/she is better or worse.”3ED, F, age 33.Only two pharmacists reported feeling confident enough to counsel ONS without further training. Three pharmacists reported not having had any training on ONS. Of the pharmacists who received training on ONS, the majority did not feel that they had acquired all the necessary training on this type of supplement. The reported reasons for this need for training seem to be based on the increased prevalence of these products in the pharmacies’ product portfolio. In general, training was provided in the pharmacy itself, through representatives of the ONS manufacturers:“I really think that there should be more training on this subject, because, in fact, it’s something that at least in pharmacy, has been increasing the number of sales, especially because we have an older population, many more pathologies (…) the basis for better counseling is really training, I think that should be part of it. To always keep up to date with the latest news about interactions and adverse reactions, (…) and it’s something that I don’t happen to know, and I always think it’s important.”10PA, F, age 26.One of the strategies adopted to overcome the lack of training was asking more experienced colleagues. In addition, the scarcity of information available in the pharmacies’ information systems was also mentioned, reflecting their inadequacy for this purpose:® [pharmacy information system], although I don’t think supplements have much information in the computer system. Because I don’t have any other sources of information, we go around making questions to each other.”“Essentially, the lab’s website or product website to get the most information or else working with SIFARMA10PA, F, age 26.®, but it has nothing good, lab’s websites and older colleagues who know!”“SIFARMA11JO, F, 27 years old.® helps a little bit but it is very limited, you can’t have any level of specification, because sometimes you can even have a “slight interaction alert” with something, but is that slight interaction significant or not?!”“The information available is scarce. I want to believe that the information, especially from the laboratories’ webpage, is information you can trust. SIFARMA1DG, F, 31 years old.In the thematic analysis here presented, three main themes were found. The first theme concerns the technical component of counseling, i.e., knowing how to advise the right product to a specific patient. This theme includes other sub-themes, such as the confidence in the counseling, which increases with the frequency of ONS dispensing; patient compliance to the ONS, reflected in the perception that the price of these ONS may hamper patient compliance, leading to lower efforts in provision of a structured follow-up; and the differing approaches to follow-up where there seems to be a dichotomy between the “should do”—as a professional’s duty—and the “can do”—identifying lack of time and inadequate information systems as barriers to this duty. The second theme was about the interprofessional collaborations pharmacists perceive as valuable for these patients. Here, feelings of insecurity when counseling certain patients drives pharmacists to refer patients to physicians (GP or others) in more difficult cases. Moreover, a special importance was attributed to the dietitian due to their knowledge and skills, which drove pharmacists to consider that dietitians’ presence or collaboration would facilitate treatment strategies and its outcomes. Finally, the last theme was the perceived need for more training and education about ONS, either at undergraduate level or postgraduate level, but more often in a professional setting, aiming to improve their knowledge on the subject but also on how to provide better follow-up.Regarding counseling, pharmacists generally understood its importance, but only a minority proactively asked patients to return to the pharmacy for follow-up. When pharmacists considered the monitoring and follow-up of a patient on ONS, they did so considering three dimensions: (1) a patient care dimension, mainly focused on identifying how a patient evolves with a given intervention, highlighting the caring role of the pharmacist; (2) a professional development dimension, concerned with improving their knowledge through experience with the use of a product or intervention (akin to the clinical reasoning cycle —they knoIn this group of pharmacists, the concern to detect situations concomitant with malnutrition, namely associated with diseases such as diabetes, renal failure, or dysphagia, was notorious. In the case of cancer patients seeking ONS, pharmacists’ choice was to immediately refer them to a physician, conveying a feeling of insecurity in counseling this type of patient. This insecurity and lack of confidence in the indication of an ONS can be partly justified both by patients’ perceptions that the pharmacist’s role should be limited only to guidance regarding the use of the medication, and the lack of training and education on nutritional care subjects ,18, reinAlongside physicians, pharmacists also mentioned registered dietitians as an alternative, as others have also done elsewhere ,32. HoweAlthough a small sample size, which can be considered one of the limitations of this study, the interviewed sample of professionals in this study reflects the demographics of the profession, i.e., a young, mostly female population, concentrated in urban areas , even thIt would be of special interest to develop new studies exploring new forms of interaction between pharmacists and dietitians, as well as studies that evaluate and determine which tools are most important for the development of information systems that allow for the follow-up and monitoring of patients using ONS therapy in a collaborative approach to nutrition care services in the community.The results of this study allow us to conclude that it is easier for pharmacists to counsel and dispense ONS than to continue the follow-up after that counselling. To implement a successful follow-up, pharmacists suggest deepening an interprofessional collaboration with dietitians and refer the need for training and education on ONS subjects and follow-up methodologies and skills.


They embody different qualities of a leader and refer to intra- and inter-role conflicts within multiple crisis conditions. Metaphor analysis reveals different self-images of ICU leadership clinicians in relation to crisis management. This illustrates that thinking and perceptions of crisis management may strongly differ between and within leaders and may change over the course of crises. Our findings highlight the need both to improve knowledge on challenges associated with leadership in crises and preparedness, and to support clinicians in their leadership by recognizing and addressing differences and changes in leaders’ self-image.The COVID-19 pandemic coincided with an already long-standing crisis in health systems around the world characterized by economic pressure and increasing staff shortage. “Crisis” became a global metaphor to convey collective experiences of the COVID-19 threat. Little is known on how crisis metaphors influence thought and speech on crisis management and the challenging staff situation of intensive care unit (ICU) clinicians in leadership positions and how they act. Therefore, we were interested in (1) which metaphorical concepts ICU clinicians in leadership use to express experiences and strategies in dealing with coinciding crises, (2) how these change over time, and (3) how metaphors in speech reveal self-images of crisis management. We conducted a systematic metaphor analysis focusing on data from three participants of a qualitative interview study with twenty-four healthcare professionals in ICUs in Germany. The participants were interviewed at two time points between April 2020 and March 2021. We identified and reconstructed metaphorical concepts of three interviewees (ICU clinicians in leadership) with regard to the pandemic management, and developed a typology based on the dimensions of mood, modus operandi, location, and scope. The typology consists of eight self-images (protagonists) for the crisis management of ICU clinicians in leadership, such as the figure of the soldier (“to unite everyone behind this flag”), the distributor (“sometimes it is a crazy patchwork [ Thus, iGenerally, “crisis” describes a situation in which major challenges of adaptation, coordination, and possibly modifications and protection need to be solved in a short time . HistoriIn contrast to the long-lasting crisis in health systems, in this article, we define the pandemic as a  crisis by addressing its cyclical structure. Regarding the different waves of infection, we do not identify it as a long-term and lasting state, but consider within this phenomenon partially sequential  crises (“crises within crisis”) . We defiIn framing the pandemic as a global emergency and “the outbreak of war” , politicEspecially at the beginning of the pandemic, we saw unimaginable situations in ICUs in some countries. In the media, scenarios of overcrowded hospitals spread around the world: temporary camps with care equipment to treat a mass of critically ill patients in hospitals, isolated dying SARS-CoV-2 infected persons, and health professionals gasping for breath, due to working with limited resources under ongoing pressure .While the beginning of the COVID-19 crisis in hospitals was characterized mostly by limited protective equipment and limited health care capacities for an unusual increase in the number of critically ill patients, a concrete image of the fundamental crisis in health care systems was missing. Aspects of human resources and working conditions in hospitals became more visible under pandemic conditions in the public , especiaPolitics and the media used a variety of metaphorical concepts to express and order the complex experience of the pandemic that also became part of people’s everyday language , 17, 18.According to a basic understanding of Aristotle, “a metaphor consists in giving the thing a name that belongs to something else; the transference being either from genus to species (…), or on the grounds of analogy (…). One will accordingly describe evening as the ‘old age of the day’ (…) and old age as the ‘evening’ or ‘sunset of life’” . FollowiFrom a cognitive linguistic perspective, Lakoff and Johnson take a broader stance and define the essence of a metaphor in understanding and experiencing a certain subject in terms of another . The maiIn the context of what has been described as a “collapsing system” in many countries , 23, resThis study aims to help filling this gap by exploring the metaphorical expressions of CM in ICU clinicians’ experiences in the co-incidence of the COVID-19 pandemic and staff shortage in health systems. By focusing on metaphors, we explore how words/word groups are transferred from their original context (source area) into a different one (target area) . Doing s2.At the beginning of the COVID-19 pandemic, we initiated an exploratory interview study focusing on experience and practices of HCPs in German ICUs during the pandemic. We used a grounded theory approach. Between the end of March 2020 and March 2021 we conducted individual interviews with 39 ICU HCPs, namely 19 nurses, 17 clinicians (nine clinicians with leadership position), and three medical students; 24 participants were interviewed twice. The participants were recruited through e-mail, telephone, professional networks, flyers, and personal contacts. For each interview, a protocol was prepared which reported important aspects. The interviews proceeded without interruptions or complications. In addition, the research group prepared for possible complications , for example, by providing contact options for counseling services if necessary. A detailed description on the methodology can be found in Hörold et al. .In our study, we described negotiations of social practice and interaction at the beginning of the COVID-19 pandemic in Germany and found a complex field of ambivalences between habits and the new normality of a “daily routine of preparation” . We repe2.1.The three interviewees we focused on with metaphor analysis were clinicians in leadership positions working in ICUs, which we briefly portray below. We chose the three interviewees based on common characteristics. First, the clinicians were in a leadership position in hospitals of centralized care, had similar work experience, and were involved in the same way in structures and processes of working in the ICU during the crisis’ phases. Second, the interviews were conducted at comparable time points (baseline interview May 2020 and the follow-up November/December 2020). Third, the three interviewees were of similar age (midlife) and ethnic background . We do not include gender identity and use pseudonyms for our participants (cases 1–3).Case 1 (C1) is an ICU senior clinician. C1 had more than 10 years of clinical work experience and a similar amount of experience in intensive care. C1 worked in a hospital in a COVID-19 hotspot and considered this time to be incredibly exhausting.A further participant we interviewed was a head clinician defined as case 2 (C2). C2 had more than 10 years of work experience as a physician. Their perspective on working in the hospital changed from baseline to follow-up interview. While C2 was highly motivated in the first interview, C2 expressed being more vulnerable in the second interview.Case 3 is the third participant in our study. The senior ICU clinician had more than 20 years of work experience at the time of the first interview. In the baseline as well as the follow-up interview, C3 was critical of the working conditions and the political CM. C3 described their own experiences in managing the first phase as a state between disbelief and anger.2.2.We understand metaphors of ICU clinicians as cores of narratives. While narratives are used to deal with divergence in everyday experience, metaphors additionally mediate the meaning of them . MetaphoSchmitt proposes a systematic approach to the analysis of metaphors that involves successive steps . Prepari3.Our typology defines characteristics of CM protagonists on four dimensions . The dimThe protagonists show how clinicians take responsibility for CM in ICUs. They (inter)act in different ways. The order we present the types in this section mirrors their chronological development during the first pandemic year. In the course of data analysis, the majority of the protagonists appeared to us as either male or female. We found that the respondents already gendered the metaphorical repertoire of the protagonists. As a result, six out of eight protagonists are portrayed as gendered.3.1.Schweinsverlauf] – C1, 1). He is afraid of being defeated: .We found the adventurer protagonist primarily in the baseline interviews. What is remarkable about this protagonist is his enthusiastic mood and motivation in finding CM strategies for the unexpected situation in the ICU, for which he assumes responsibility. By actively searching for an image of the future (“(…) we had no idea what was coming” – C1, 1), he pursues experiencing adventures inspired by action movies (modus operandi). With innovative ideas (“That’s why I invented (…) so-called (…) teams” – C2, 1) and energy to “consistently” combat the pandemic, the adventurer aims to shape his workplace, has effective self-management skills, and restructures processes in teamwork in order to improve them . He regards CM as a sporting event  and he performs the role as a coach (“leader”) who trains his team under time pressure (“breakneck speed” ,” “I cannot describe it in any other way, (…) the first six weeks were hell” . We see the survivor as a protagonist who emerges from dealing with impositions. The metaphorical repertoire of this protagonist consists of an iconography of the inconceivable, expressed in images of the monstrous and evil. For him, CM means to overcome “a monstrous task” . The survivor shows a high level of confidence in CM to successfully deal with the crisis together . At the same time, he is proud of personal and joint achievements . His modus operandi is to live on. From this, he often feels powerless and yet prescribes a positive way of thinking, e.g., by repeating affirmations  or by telling a story of comforting endings ” – C3, 2).The survivor is a protagonist who only emerges in the follow-up interviews. He is currently in a safe place. CM is reconstructed negatively, in metaphors of strength and effort, but also marked by an underlying anxiety . The survivor can be characterized as tough and resistant (mood), even though the pandemic took his strength. “I phoned through three batteries from the phone. That was absolute madness [3.4.wahnsinniges Gestückel]” – C3, 2) and considers his role as “filling the gaps” .We found the protagonist of the distributor to be a consistent embodiment of the CM of clinicians during the pandemic and the economic conditions in hospitals. He can be characterized as being engaged and creative, but also rational. He plans and allocates commodities/resources . He regards CM as a puzzle . In the preparation phase, “the extreme bottlenecks [Engpässe] in basic deliveries” were very stressful because “the quality decreased significantly as the price increased” , for example in personal protective equipment. “At the moment, we have these filter bags [Filtertüten] that you put on there” . The distributor was responsible for the allocation and stocking of the materials – “we had to let people work with it (…)” . Another important point is the acquisition and deployment of (new) employees. He manages the staffing of the units and regulates absence rates. (“(we) have more people in the pot, so to say.” – C3, 2). The distributor uses various possibilities to recruit staff for the ICU, e.g., by offering “experience tours”. He organized patient care  and at the same time “(…) selected the physicians who seemed to be the most suitable (…)” . In the course of the pandemic distribution got more arduous  somewhere” – C3, 2). We have three scenarios for the protagonist “distributor”: first, we can locate him in the headquarters of an industrial company, a location where he can oversee the entire situation. Secondly, he can also sit in front of a puzzle board, or be a cutter in a tailor’s shop. The metaphorical repertoire shows him as a person who tries to be as best as possible in his leadership role with increasing burden at the same time .The distributor struggles with having equipment, beds, and human resources available, or not. Since he is prospectively oriented (“scope”), it is important for him to receive “very early and timely this stuff” . “Frankly speaking  in my life, I’m a master at it, I can do better than pneumology” . He identifies himself with practical activities that are carried out manually . Hands are presented in their functioning as creative tools of humans. They stand for empowerment to act. The image of a helping hand was adapted to a “helping clean hand” . It characterizes the craftsman’s hygiene-compliant work in the hospital setting and represents a high-quality standard and a respectful treatment of patients. This protagonist obeys the traditions and virtues of his guild. He aims to manufacture a product that is useful in everyday life . His modus operandi pursues the construction and reconstruction of high-functional elements. From this perspective, manual contribution is temporally limited (scope), as it is intended only to overcome a crisis in an unexpected scenario. Craftsmanship is not oriented towards technical progress, but it is used to process the resources that have been distributed in a high-quality way. In doing so, the craftsman is highly motivated and engaged.The craftsman applies his knowledge of building modular furniture or elements and uses irony to talk about his professional work as a clinician: “I have built many PAX cabinets  is needed,” and “teaching and training” to form strategies and new routines. That means she tried “to get as much information as possible from the countries that were already badly affected”  by watching many interviews from Bergamo in northern Italy. She “tried to look at ways that had gone well ” and screened research papers. Her mood is motivated, yet guided by concern, “especially since the patients were really extremely bad. And that is a point that we had to learn” .In this crisis phase, “brainpower [ein Lehrstück]”  as is required on completion of a professional education. It suggests that new routines are developed and professionalized . That is perhaps also a difference. “We are much better prepared and have also learned that we can activate all this within less than a day” . From our point of view, the trainee is a lively and curious person who is in a school scenario. In this environment, she is confronted with information that quickly becomes outdated. “The standard two days ago was so old that it (he) has already grown a beard” . The metaphorical concept provides associations with a fairy tale scenario. Thus, at the end of a fairy tale, the reader is always entrusted with the message of a morale. In the crisis story of the pandemic, the trainee learned the lesson of effective preparation to take responsibility for her staff.The image of “rocking along with you”  characterizes the trainee (in leadership role). She wants to support and empower their employees – “that everyone can simply fall back on it and also know what is meant by it, also understand it” . Consequently, she associates learning with intellectual aspirations. The metaphors in the follow-up interviews describe CM as “a journeyman’s piece [3.7.The parents are protagonists we found both in the baseline and in the follow-up interviews in a prudent mood. For parents, CM means caring and protecting each other; employees become their children . Parents evaluate the current conditions, and care on outcomes in the future (prospective scope) .However, the pandemic changed the role of mothers/fathers. At the beginning, we observe parents who are concerned about health protection: “So now that I know, well, these are the best-protected employees, I am calm, but I had to learn that” . They reveal that it was important to build a sense of belonging to a community .In the follow-up interviews, they are concerned about the workload. The employees “(…) (have to) do things now that we would not usually make them (to) do. And I would not like to put them through that right now either, but there’s no other way and they are all doing great” . Parents feel responsible and helpless at the same time. They “put them (employees) in work situations where (the parents) know that they cannot do their job in the best possible way. (…) firstly, we overwork the employees, secondly, they go home and have the feeling ‘I could not do my job optimally today’. Yes, and thirdly, they are always afraid of being infected” . Parents are proud of their children (employees)  and emphasize “to strengthen the team” . At the same time, they feel devalued by their fellow citizens, and perceive these reactions with skepticism and concern. “(…) in the spring we were the heroes, now we are the bogeymen for everything. So we are the bogeyman for everything, really” . We perceive parents in a conflicted life phase scenario. On the one hand, they intend to give their children the freedom to unfold freely, but on the other hand, they worry about them because of the evils of the world. In addition, they are disappointed that they receive little recognition for their achievements (care work) in society.3.8.In the follow-up interviews, we found metaphors that emphasized the protagonist “critic” more explicitly. This person reflects on operating costs and hospital financing in the German health system. The critic is unisex. We used the singular they.The critic introduces a meta-perspective on the system  and on themselves as part of it . They monitor and evaluate new policies regarding the COVID-19 crisis with attention to the ongoing crisis in hospitals. The mood is “bitter” and cynical, the perspective is rather pessimistic and “worried” . They understand the pandemic as a huge, hard-to-solve task that coincides with an ongoing crisis in health systems .The viewpoint is detached from daily routines and enables taking up a transcendent position. They use critical voice as an evaluative tool to reflect on coinciding crises and thus compensate frustration. That is why another possible scenario of the critic is working as a staff council. As an advocate for patients and ICU staff, they shed light on the economic strategy of the healthcare system, while the work within is characterized as being physically challenging and brutal . Besides a lack in equipment, they also critically mention the decreasing human resources in hospitals. They consider connections between workload and structural working conditions and the attractiveness of health professions . In the leadership role, they oscillate between employees and hospital management. This leads to contradictory and ambivalent situations, because they refer to both positions. Therefore, “job” is personified as a not-appropriate romantic partner with whom a person spends a lot of time within their life. Similar to a dysfunctional relationship, the critic remains in the ambivalent role. He mediates between hospital management and staff.The protagonist assesses current crisis conditions in hospitals, but does not have suitable suggestions for transformation, which is why their scope is limited. To make a comparison with the continuing situation , they refer to events that lie in the past . The scope is primarily retrospective or destructive, when imagining the future . Their actions  depend on the system which is criticized. In case of a system change, the critic’s mission will be fulfilled and this protagonist would disappear, at least until the next critic-worthy situation occurs.4.In our study we used metaphor analysis to explore images of CM within the metaphorical speech of ICU clinicians in leadership roles. We illustrated how metaphorical language helped clinicians in leadership to make sense of their experiences in coinciding and recurring crises. To contrast differences in the use of metaphors, we selected three interviewees from our original study . The metWe applied the metaphor analysis separately to the original study , and didWith two exceptions, the protagonists are gendered. They embody professions or occupations that are traditionally ascribed as male or female in Western societies  , 53. AltOur study was conducted in the context of the German healthcare system. Compared to other countries, there is a perceived need for reforms in terms of hospital structure and financing and, above all, an increasing shortage of nurses . Our finAs the use of metaphors of CM changed during the first year of the pandemic, we encourage further research on how the pandemic and staff shortages, not only in ICUs, affect leadership self-image in the long-term. We showed that concepts and perceptions of CM might strongly differ between and within leaders as well as over time. This has implications for policy and practice, particularly for human resource management of hospitals and pandemic preparedness. In order to support clinicians in their role as leaders, it could be very important to consider their self-image and to acknowledge the differences and changes in self-images of leadership personnel in crisis situations as in general. This highlights the urgent need for policy and practice decision-makers to better understand the challenges associated with leadership in crisis and preparedness and to support clinicians in performing their leadership roles.The raw data supporting the conclusions of this article will be made available upon request by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Ethics committee at Otto von Guericke University Magdeburg, Faculty of Medicine (51/20) as well as University of Regensburg (20-1771-101). The participants provided their written informed consent to participate in this study.JP: formal analysis, investigation, methodology, validation, visualization, writing/original draft, and writing/review and editing. MH: formal analysis, investigation, methodology, validation, visualization, writing/original draft, and writing/review and editing. SB: writing/review and editing. K-PD: project administration, data curation and writing/review and editing. IH: investigation and writing/review and editing. RS: methodology and writing/review and editing. CA: conceptualisation, funding acquisition, project administration, supervision, and writing/review and editing. All authors contributed to the article and approved the submitted version.The authors disclose receipt of the following financial support for the research, authorship, and/or publication of this article: this work was supported by intramural funding.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Simulation-based learning (SBL) has become an effective tool in the education field, and instructors play a significant role in leading it. Although much is known about participants’ needs, SBL instructors’ needs have yet to be addressed. The study’s goal was to explore SBL instructors’ needs while guiding an SBL workshop using the psychological framework of Maslow’s Hierarchy of Needs.We employed a qualitative case-study design, consisting of 68 four-hour-long workshops, held at a teacher-education simulation center by the center’s professional instructors. Data collection comprised 211 statements derived from instructors’ open-ended reflections, the transcripts of two focus groups held with the instructors, and 98 interpersonal communication documents.Data were analyzed using both deductive and inductive thematic analysis, which rendered 11 themes spanning Maslow’s five levels, and revealing two possible simulation-based learning paths: a complete process, in which all needs are met and an incomplete process, in which needs remain unmet.Theoretical insights and practical implications are provided for attending to instructors’ needs  to ensure optimal learning in teacher education when using SBL. From the end of the 1960s to the mid-1980s, numerous studies applied the theory to gain an understanding of candidates’ motivations for pursuing a career in the field of education , the neeIn the last two decades, there has been a renewed interest in Maslow’s theory, with a focus on contemporary issues. Maslow’s theory has been found to be a suitable framework for understanding schoolteachers’ needs , as well1.3.As mentioned, not only is it crucial to identify SBL instructors’ needs, but once identified, we must be prepared to interpret and evaluate their impact, to understand their relative significance to the overall SBL process. To this end, we formulated the following research questions:Instructors’ perceived needs and their mapping according to MHN: what are the needs of simulation instructors when leading a simulation workshop, and in what ways do these needs correspond to Maslow’s Hierarchy of Needs theory?Instructors’ perceived SBL process in light of their needs’ gratification: What is the perceived impact of gratification of the needs in the hierarchy vis-à-vis the SBL process overall? What is the perceived impact of unmet needs on the SBL process?2.2.1.The research was conducted at a simulation center at a higher-education institution in Israel that operates in accordance with the clinical simulation model. This model involves professional actors  and is frequently used by The center is located in the school of teacher education and its content is coordinated with the teacher education program. It provides services to both preservice and inservice teachers in separate groups. Inservice teachers participate in SBL as part of their professional development courses, whereas preservice teachers typically participate in SBL as part of a course in pedagogy. The students attending the center represent a multicultural cross-section of Israeli society, which includes Israeli Jewish students , Israeli Arab students , and new immigrants.The current study was carried out over 2 years. The staff of the simulation center consists of 29 instructors and 14 professional actors. Workshops are guided by a single instructor, who has received special training for this purpose. Most of the instructors are the college lecturers, whereas paucity hold a background and contemporary employment that is highly related to teacher education. Specifically, most of them are the college’s pedagogical teacher educators, whereas some are senior schoolteachers or hold a managerial position in their school. In addition to the specialized training they receive at the simulation center, they usually hold prior additional certifications as group mentors or coachers; thus, they have education-oriented backgrounds as well as field experience leading groups. The simulation center’s staff, including the simulation instructors, the center’s administrators and the research unit meet regularly to enable knowledge sharing and brainstorming on how to best design and improve the quality of the teacher-education simulations. Each simulation workshop lasts 4 h and comprises approximately 12–15 participants. Pre-workshop preparation includes an in-depth conversation held between the group’s coordinator and a center staff member, during which the main needs of the group are identified. Next, the instructor receives additional information about the incoming group’s characteristics; then, tailored scenarios are written by the center’s professional content developers (scenario writers). Each workshop consists of three different scenarios typically involving conflictual situations that are common in the field of education. The SBL workshop process involves three experiential cycles that follow the same procedure but are diverse in terms of content. Each of these cycles includes a scenario-based simulative experience – that is, a five-minute enactment of the scenario by professional actors interacting with a group member in real-time, during which the actor responds according to predefined schemes written into the scenario – followed by a debriefing phase. The interactions are video-recorded (using the SimBoost platform), with the assistance of a technical support team, and the debriefing phase is conducted by the instructor, during which a variety of theoretical coping-strategy models are presented. Finally, as part of the debriefing process, the actors present their feedback to the workshop participants, providing the participants with a unique opportunity to receive direct and authentic feedback on how their behavior was experienced by others. 2.2.Gaining insight into the subjective needs of instructors called for a qualitative methodology . In this2.3.Employing a purposive sampling method, 29 simulation center instructors were approached, yet it was emphasized that participation was voluntary. Eventually, 22 instructors agreed to participate. Data from 68 workshops were collected over a two-year period , using multiple data sources, to provide a comprehensive understanding of the issue, allow for the triangulation of findings , and theInstructors’ post-workshop reflections. Following each workshop, instructors were asked to freely elaborate about their experiences during the simulation workshop . Overall, 68 reflections were collected, yielding 211 statements.Focus groups. Two focus groups were conducted at the end of each year (10 participated in the first-year focus group and 12 participated in the second-year focus group). During the focus groups, the participants were requested to discuss their needs when leading a workshop as well as to respond to others’ comments . Focus group sessions lasted one and a half hours and were audio-taped and then transcribed.Instructors’ email correspondence documents. Documents containing email correspondence between the center’s academic manager and the 22 instructors were collected. Overall, 98 documents were reviewed.The rationale for collecting data from multiple sources lies in the assumption that richer information will be derived this way. The inclusion of personal reflections are recorded privately and covey thoughts and emotions that might not be shared in a group. By contrast, focus groups are conducted collaboratively and publicly, where interpersonal interactions can trigger new insights and perspectives. The rationale for examining email correspondences between instructors and academic managers was that this medium is often used by instructors to discuss challenges and experiences following an SBL workshop, thus, providing important data about the instructor’s needs.Prior to data analysis, all data were coded as follows: instructors’ reflections were coded sequentially (REF-W1—REF-W68); focus group data were coded in accordance with the year in which they were conducted ; and instructors’ correspondence documents were coded chronologically (ECO1—ECO98).2.4.Data from a preliminary pilot study of simulation instructors  revealed that the instructors’ needs could be mapped to the MHN framework. Thus, the MHN framework was chosen as the theoretical lens through which the entire data were analyzed and through which the issue of needs was examined. This analysis was conducted in a two-step thematic analysis procedure, as follows. In the first round, we performed a deductive analysis, using MHN as a theoretical framework through which to investigate the perceived needs of the instructors when leading simulation workshops. At this stage, data from all sources were coded based on Maslow’s five levels of human needs, while we remained open to additional levels or needs not mentioned in MHN. We calculated the frequency with which each theme appeared in each of Maslow’s levels, across all data sources, to gain a sense of the prevalence of the various themes. During the counting procedure, we took note of instances where the same instructor mentioned the same workshop-related theme in different data sources. In such cases, the theme in question was counted only once.In the second round, we employed an open thematic analysis, which is inductive in nature. During this inductive analytic process, data segments that were identified in the previous round as reflecting instructors’ needs were analyzed, as we searched for salient themes emerging from the text. Similar or related themes were grouped together. This microanalysis was used to ensure that no important ideas, themes, or constructs were overlooked. This process yielded 11 main themes along Maslow’s five levels. Eventually, we were able to organize the emergent themes that represented instructors’ needs according to MHN. Then, we calculated the frequency with which each theme appeared in each of Maslow’s levels across all data sources, to gain a sense of the prevalence of the various themes. During the counting procedure, we took note of instances where the same instructor found a particular workshop-related theme in more than one data source . In such cases, the theme in question was counted only once. Working separately, we (the two researchers) initially read and analyzed the material, marking and coding the relevant themes and subthemes, and then ascribed each of these themes to one of the five levels of MHN. Subsequently, we compared our findings and discussed them until we reached a joint decision regarding the relevant themes at each level. Finally, member checking, which is considered the gold standard for establishing trustworthiness , was emp2.5.via a link to a Google Form, enabling them to refuse without being inconvenienced. Confidentiality was maintained, as answers were anonymous. Before conducting the focus group, the instructors gave their consent to have the session recorded, and they were explicitly told that they could choose what they wished to share, and were free to leave at will, without consequence. Focus groups were recorded and transcribed; all personal information was concealed and, hence, pseudonyms are used herein.This study’s protocol was approved by the higher-education institution’s Ethics Committee. The participants gave their informed consent. The request that they write their reflections was sent to instructors 3.First, we will describe the themes that emerged as related to instructors’ needs during SBL, while considering the ways in which these themes correspond to MHN. Then, we will focus on two possible SBL pathways that demonstrate SBL outcomes when needs are met as opposed to when they are unmet.3.1.The findings unveiled the various themes that represented instructors’ needs and the ways in which these needs resembled those of MHN. 3.2.Based on the analysis, 39% of the instructors’ reports (82 phrases) described needs that corresponded to basic needs on the MHN framework. That is, the instructors indicated that these items were essential for them to be able to perform their duties during workshops. These comprised both generic needs and specific simulation-workshop-related needs, as elaborated below.3.2.1.equipment needed for operating the workshop was mentioned as a primary and significant concern: ‘The binders with the forms were not well-organized. I had to search for the correct form … We had to do last-minute photocopying … how am I meant to manage the workshop efficiently like this?!’ (REF-W31). The presence or absence of technical equipment was experienced as enabling or impeding the instructor’s operation of the workshop. Judging from the tone of these comments, it appears that having equipment-related difficulties was a frustrating experience.The 3.2.2.being able to use the video system properly during the debriefing process was experienced as essential to the instructors’ functioning: ‘Because of technical problems in the video system, I was unable to use it throughout the debriefing stage. It complicated everything for me’ (ECO2). In such cases, instructors noted that the assistance of a technical support team was beneficial.Other basic components needed were essential to the simulation, specifically the video recording and the scenario. First, adequate and adapted scenario was experienced as fundamental to instructors’ ability to successfully lead the workshop.Second, an I once had a team of teachers who worked at a boarding school for high-risk students and had no interactions with the students’ parents. Yet the scenario focused on teacher-parent relationships. The debriefing was dull. I had to try much harder to make something out of it … in order to best function I need you to carefully select the scenario (FOCGR1).In other words, when the scenario fails to correspond precisely to the profile of the workshop participants, the instructor’s ability to focus the debriefing phase on the predefined goals is hindered, and thus the workshop fails to address the participants’ needs.Interestingly, the abovementioned needs were typically mentioned at the beginning of the instructors’ descriptions, and if these needs were not met, their style became laconic, and they offered no further elaborations about other, higher-level needs. This observation further suggests that these needs were fundamental to instructors’ functioning. Instructors also mentioned a human-based element as basic to their functioning: the professional actors.3.2.3.quality of the actor’s performance and the actor’s feedback. Specifically, the better the actor’s performance, the more authentic the experience was for the participants, thus facilitating the instructors’ work: ‘The actor performed his role so well! It significantly helped me deliver my main message, as the situation was experienced as authentic and thus initiated behaviors that align with the predefined key issues’ (ECO88). Furthermore, the actor’s feedback during the debriefing helped instructors to lead the group to the predefined goals.According to the instructors, the participation of professional actors provided them with the optimal conditions under which to conduct the debriefing phase. Two elements were of particular importance: the The actor is able to deliver a complex message since it is based on his or her own experience during the simulation. This is all the more evident when the actor listens to the discussion held and internalizes the key points I am striving for, and then accommodates the feedback to these key points (FOGR2).In fact, some of the instructors noted that they deliberately coordinated with the actors to obtain their cooperation in the debriefing stage. Thus, it appears that the actors’ professional performance, feedback, and collaboration were perceived as essential basic ingredients for instructors’ optimal functioning.3.3.Data analysis indicated that 7.5% (16 phrases) of the instructors’ reports referred to issues of security. According to 3.4.Instructors related to their internal sense of emotional security, which stemmed predominantly from how well they were able to lead the workshop and seemed to depend on their prior professional training: ‘Unfortunately, I did not come sufficiently prepared to lead the workshop … I would have felt less threatened if, during the initial training, we would have gained more first-hand practice in leading a workshop’ (ECO12). The better instructors’ preparation was, the more they seemed to experience a primary sense of internal security in leading the workshop. Yet this sense of security was also affected by externally-based influences, as elaborated below.3.5.Frequently, an authority figure  attends the workshop along with the participants, a situation which can undermine the instructors’ status and emotional security: ‘The only challenge I had to cope with was the presence of the supervisor, who openly expressed her dissatisfaction with the way I was leading the workshop’ (FOGR2). Receiving criticism from authority figures during workshops may directly impact instructors’ sense of security, but their presence may also have an indirect effect on instructors’ sense of security:It would be very helpful if the group supervisor was not present … This had a negative effect on me, as it seemed that some of the teachers felt completely blocked and the conversation was stilted … I felt their tension … They couldn’t speak openly. It made my job much harder (REF-W61).As shown, the authority figure may indirectly affect the instructor’s sense of security: when the participants feel threatened, they are less willing to openly engage in the debriefing process, and the instructor is thus forced to lead the workshop under challenging conditions. 3.6.Forty-three phrases (20%) dealt with issues of belongingness. Within this level, two themes emerged: the first relating to ‘regular’ ongoing situations and the second being relevant in cases of group diversity.3.6.1.Instructors’ collaboration with the group during the workshop was described as crucial to their ability to create an atmosphere that promotes learning. When this collaboration was suboptimal, instructors’ functioning was hindered:My interaction with the group was problematic. No one volunteered to participate in the simulation; they were quiet and not responsive. Some spent much of their time on their mobile phones. It was really difficult because I need to properly communicate with them to be able to function at my best (REF-W17).Generally, instructors mentioned the need to work harmoniously with the group when guiding the workshop, for the sake of optimal operation of the workshop . This need for belongingness was potentially challenged when facing specific cases of cultural diversity.3.6.2.Some instructors perceived the group’s cultural background as potentially challenging to their sense of belongingness. To face this challenge, they searched for information about the group beforehand, to become familiar with its practices.I had a workshop with a religious school, and I’m glad that a few days beforehand I entered their school’s website and learned who they are and which projects they undertake. I did that because I am not religious, and their worldview is so different from my own. Later on, during the workshop, when they spoke about the project, I knew what they were talking about, so I wasn’t an outsider (FOGR1).As shown, familiarizing themselves with the group’s cultural characteristics may help instructors to ‘work in harmony with the group’, particularly when the group’s background is unfamiliar to the instructor.Not sharing the same native language presents another intercultural challenge. As described by a Jewish Hebrew-speaking instructor who managed an SBL workshop for a Bedouin group:During the group discussion, they repeatedly commented to each other in Arabic, and I don’t know Arabic. If I knew Arabic, these comments could have been further developed during the discussion … and to be honest, at a certain point they were laughing and I wasn’t sure whether they were laughing about me or about the topic discussed (REF-W25).they know … I do not), which precluded any sense of belonging. In such cases, the instructor’s ability to communicate and ‘join’ the group is impeded. Consequently, instructors’ ability to lead the collaborative discussions is impaired, and they may experience a sense of disconnection from the group.It is worth noting that the instructor positioned herself outside to the group  of the instructors’ reports dealt with issues related to self-esteem needs, which is in line with 3.7.1.Instructors’ self-esteem needs manifested first and foremost in their self-reflection about their competence and functioning: ‘I wonder how I can do it more effectively … I’m not sure whether we went deep enough’ (REF-W46). This engagement in a self-reflective process was present in many instructors’ reports and appeared to focus on instructors’ sense of competence in achieving their highest level of professional functioning. This concern aligns closely with one of the aspects  that comprise self-esteem needs according to 3.7.2.Another aspect of self-esteem, according to Maslow, is the need for recognition and appreciation. Indeed, positive participant responses seemed to be very important to the instructors: ‘The participants’ feedback was very warm; they said it had been a meaningful experience. They even asked to have an additional future workshop with me’ (FOGR1). The phrase ‘with me’ implies that the instructor viewed participants’ feedback as reflecting the appreciation of his or her professional performance, thus nurturing the instructor’s self-esteem. In fact, most of the instructors explicitly asked to review their group’s formal feedback forms, an indication of their perception that the group’s final feedback was an evaluation of their performance. 3.8.realization of the instructor’s role and the instructor’s experience of satisfaction.The analysis revealed that 21.5% (45 phrases) of the instructors’ reports dealt with issues related to self-actualization, which in MHN involves reaching one’s potential and desired goals. Two interrelated themes emerged at this level: 3.8.1.Interestingly, many instructors began their responses by referring to what they perceived as the learning outcomes.There was meaningful learning … students said that they felt better prepared to face challenges in their practical work … I can clearly see that they leave the workshop better equipped for their jobs and I find this very fulfilling … at the end of the day, this is why I’m here (REF-W38).Self-actualization occurs, according to 3.8.2.When they were able to successfully realize their role as mediators of the SBL learning process, the emotions experienced by the instructors included enjoyment, reward, and a sense of satisfaction: ‘I felt that I had contributed to the participants’ professional development and that was so rewarding. I enjoyed it’ (ECO-47).In contrast, when self-realization was not achieved, the emotions experienced included frustration, despair, disappointment, and sometimes bitterness. ‘Frankly, I am quite disappointed …. We did not gain much learning. So frustrating!!’ (ECO-56).cognitive process, during which instructors examined whether their ultimate goal of mediating the learning was achieved, whereas the second focused on their emotional experience as a result of this achievement or lack thereof.In conclusion, self-actualization consisted of two aspects: The first involved a 3.9.The following section describes the process of a successfully completed SBL process vs. an incomplete SBL process, depending on whether the hierarchical needs were fully or partially met, from the instructors’ perspectives.3.9.1.The analysis revealed that 62 of the 68 workshops reviewed in this study corresponded to the complete process. In this path, all five of the hierarchical levels of needs were addressed in the simulation workshop: a condition that enabled the instructor to achieve self-actualization. As we analyze Debra’s  description of her experience as an SBL workshop instructor, we find that her sense of self-actualization (level 5 need) includes the fulfilment of her needs from all of the preceding levels.The simulations contributed a great deal [level 5–self-actualization]. The students explicitly expressed their enthusiasm [level 4–self-esteem]. I have been working with this group since the beginning of the academic year and there was a pleasant atmosphere [level 3–belonging].As can be seen, no mention was made of first or second-level needs (neither basic nor security needs). Disregarding these first two levels was typical of cases in which a complete process had taken place, most likely because when fundamental needs are met, there is no need to mention them. However, when these two basic-level needs were not met, their absence was very conspicuous, as shown in the following section.3.9.2.Six of the 68 workshops conducted corresponded to the path of ungratified needs. In these cases, the instructor reported that the goals of the SBL were not achieved and, to explain why, referred to one or more needs that remained unfulfilled throughout the workshop. Workshops that do not achieve their predefined goals constitute an important test case, through which lessons can be learned and improvements can be made. It is thus worthwhile to present the following two examples of workshops that were conducted by different instructors and involved different target populations. The analysis and MHN-related conceptualizations of the excerpted quotes regarding ungratified needs are presented in brackets.Lea’s report, after conducting an SBL workshop for preservice teachersThe pages and forms were disorganized; the tablets didn’t work (at the last moment I had to photocopy pages) . In general, I’m not sure whether we were able to delve deep enough or whether I allowed the group enough room for participants to express themselves . … When the students arrived, they were very tired and resistant, so they did not really cooperate. I didn’t feel comfortable in the group, I actually had to disarm their resistance . The group’s pedagogical mentor was present at the workshop and she felt it was important that she have her say. I asked her to enable the group members to express themselves . But all in all, I’m not sure to what extent we were able to delve into the essential matters. Quite disappointing, I must admit [level 5 – self-actualization].Naif’s report after conducting a workshop for a group of inservice teachersFrom the beginning I felt that the relationships among the school staff were loaded and problematic, I found myself wondering how I should fit in [level 3 – belonging]. In the first simulated round, the participant could not be heard, due to a bug in the video system . Throughout the workshop, the passive resistance was palpable and had a significant effect on the entire process . In the second round, there were no volunteers. The vice-principal of the school was present and intervened, which in my view, prohibited an open discussion during the workshop . My numerous attempts to break down participants’ resistance were only partially successful . What a waste of valuable resources!! [level 5 – self-actualization]The SBL workshops that were characterized as ‘incomplete’ were described in greater detail (manifested in the length of the transcript text) than those characterized as ‘complete’ (shorter segments in the transcripts). Additionally, these longer descriptions tended to describe the process in a way that aligns with Maslow’s hierarchy. By providing these lengthy descriptions, the instructors inadvertently attributed the lack of completion of the SBL process to their needs that remained unmet.4.Using Maslow’s Hierarchy of Needs as a theoretical framework, the current study provides theoretical insight into the needs of SBL instructors. As these instructors are the ones mediating the learning process  by leadiOverall, we were able to link instructors’ needs with the principles of Maslow’s theory , which p4.1., providing adequate equipment is basic to instructors’ ability to manage the simulation. This finding aligns with The fact that certain needs  were mentioned early on in the instructors’ descriptions suggests that these were fundamental to the SBL instructors. Moreover, whenever these needs were not met, the instructors were concise in their comments and did not elaborate further about higher-level needs. These two features together indicate the fundamental nature of these needs, in line with MHN. Findings suggest that to meet instructors’ basic needs, the following three issues should be addressed: First, in accordance with scholars’ recent claims , who argsuitable scenarios is imperative to instructors, as it creates a sense of authenticity that facilitates instructors’ role. Although authenticity was previously documented as crucial to workshop participants’ experience in SBL  and the perceived feedback from the group .In accordance with MHN’s fourth level, which involves the need to be competent and to achieve, as well as to be recognized and appreciated , instrucparticipants  the self-actualization of instructors requires the meeting of all prior needs in the hierarchy, and (2) conversely, instructors’ unmet needs hinder their self-actualization and result in experiences of frustration and disappointment. Hence, it is essential to design workshops in a manner that ensures that all instructors’ needs are met, to optimize the likelihood that they will realize the workshop’s goals.5.participants’ needs (instructors’ needs and the components that may promote effective SBL from the instructors’ perspectives. In fact, instructors’ needs may be viewed as an indirect factor that ultimately affects the quality of teachers’ SBL experience. As such, the study contributes to the ongoing conversation regarding the ways in which learning through simulation can be understood and improved to promote teachers’ learning. The study has a few limitations. First, it is possible that instructors’ reflections were influenced by response biases. To minimize this possibility, a triangulation of research sources was established. Second, as the sample comprised mainly females, transferability may be limited. However, given the gender imbalance in the field of teacher education (The study’s major implication for teacher education lies in the focus on the instructors’ needs, given that they are the ones who facilitate teachers’ learning through simulation. To date, the literature on educational simulations has focused solely on the workshop s’ needs . The curducation , we beliducation . For exa6.basic needs may be attended to by providing adequate equipment, designing suitable and authentic scenarios, and employing professional actors; security needs may be met by preparing instructors to face unexpected challenging situations and by providing preliminary training focused on handling perceived sources of threats when leading a workshop; to create a sense of belonging, instructors should receive cultural-competence training, to learn of ways to bridge potential gaps; self-esteem needs may be addressed by allocating time for receiving participants’ reflections and encouraging instructors to engage in self-reflection as part of their need for self-evaluation. Ultimately, all of these are ways to help instructors experience self-actualization and satisfaction. Given that SBL is becoming an integral part of teacher education and considering the essential role of the instructors in facilitating teachers’ learning through simulation, understanding how to address instructors’ needs and how to design optimal training for SBL instructors in teacher education is imperative. Future studies may opt to focus on instructors’ needs in the context of virtual simulations to further broaden our understanding of whether and/or how instructors’ needs are manifested differently in this context. To this end, studies should be conducted in a range of contexts, for example, in a multicultural framework, and with different participant populations. Furthermore, future studies should aim to explore whether these needs are shared across different learning environments or whether these are unique to SBL. To conclude, the current study underscores the importance of attending to instructors’ needs, to ensure that they can use the simulation tool in teacher education to its full potential.As instructors play a significant role in SBL, the current study contributes to the existing literature of teacher education by providing an in-depth theoretical conceptualization of SBL instructors’ needs and highlighting the importance of addressing them, to provide teachers with the best possible learning conditions. Addressing the study’s goal by demonstrating the SBL instructors’ needs vis-à-vis MHN enhances the theoretical understanding of this phenomenon and provides applicable insights that can be assimilated in SBL instructors’ training. Specifically, efforts should be made to address instructors’ varied needs, as follows: The original contributions presented in the study are included in the article/Supplementary material, further inquiries can be directed to the corresponding author.The studies involving human participants were reviewed and approved by Achva academic college ethics committee. The patients/participants provided their written informed consent to participate in this study.All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.