Background: This paper contributes to the ongoing work of the ISAGA Special Interest Group (SIG) on Game Science, coordinated by em. prof. Jan H.G. Klabbers since its initiation in October 2021. It builds on the themes explored during the ISAGA Symposium ‘On the Architecture of Game Science’ (Simulation & Gaming, 49(3), June 2018). In this article, we further develop the scientific foundations of Game Science by advancing the understanding of the facilitator’s role through a systems-theoretical intervention framework. Method: Considering the continuum from rule-based to open games, we present systems theory to enlighten the role and function of the facilitator. First we explain on the role of Argyris’ learning levels, and then apply Ashby’s Law of requisite variety to offer guidelines on when, with what, and how to intervene from an adaptive systems perspective. Additionally, we illustrate how Beer’s Viable Systems Model provides facilitators with an adaptive analytical tool for defining when, how, with what and where to support learning. Outcome: This paper scientifically supports the role and function of the facilitator by conceptualizing facilitation along the continuum of rule-based, hybrid, and open games, enhancing learning across this spectrum. Conclusions: This framework offers a scientific foundation for facilitators to decide when, how, with what to intervene, while providing clear guidance for their role in enhancing learning across different types of games.

Purpose of the Research: This article explores simulation games (SGs) as epistemic and cultural artefacts, focusing on the role of media of representation in shaping knowledge creation and meaning-making. Drawing on perspectives from the anthropology of knowledge and epistemology, we argue that SGs communicate knowledge through symbolic forms - such as language, rules, gestures, and interactions - that are socially negotiated and context-dependent. These media embody specific worldviews and values, and their interpretation is co-constructed by designers, facilitators, and players. The purpose of this article is to provide a scientific definition of media of representation within game science.

Major Findings: We further examine the epistemological foundations of SGs through the lens of constructionism and constructivism, highlighting how players engage with both tacit (System 1) and explicit (System 2) modes of knowing. This dual engagement has significant implications for game design, facilitation, and scientific analysis. While analytical game science often privileges explicit knowledge, we emphasize the importance of embodied and intuitive understanding in gameplay and debriefing.

Conclusions: Our findings highlight the added value of an integrative framework for game science that explicitly links media of representation with cognitive systems and social processes. We show that simulation games function not only as interactive systems but as knowledge ecologies, where tacit and explicit knowing are shaped, exchanged, and transformed through media of representation. This perspective advances game science by clarifying how games actively mediate perception, interaction, and learning, rather than merely reflecting reality.

Background: Effective teamwork and communication are crucial in surgical settings to ensure patient safety and deliver high-quality care. Operating Room Nurses (ORNs) play a critical role in managing complex technological environments and coordinating with multi-professional teams. Despite the recognised importance of teamwork, limited research exists on how ORNs perceive and experience teamwork and learning in paediatric operating rooms. Aim: This study aimed to explore the perceptions of operating room nurses regarding teamwork and learning processes within paediatric perioperative care settings. Method: A phenomenographic design was employed, involving semi-structured interviews with ten ORNs who had completed an advanced course in perioperative paediatric care. Participants were selected through purposive sampling from six hospitals across Sweden. Data were analysed using a seven-step phenomenographic approach to identify variations in understanding. Results: Two distinct approaches to teamwork and learning emerged: a team-oriented approach, emphasising shared experiential learning and communication within the team, and a personoriented approach, focusing on individualised patient care and preparation through diverse informational resources. Subcategories included ‘Communication ‘and ‘Reading about the patient, ‘highlighting the importance of interprofessional collaboration and holistic patient understanding. Conclusion: The findings highlight the dual perspectives of teamwork and learning among ORNs, with implications for improving patient outcomes and safety. Integrating both team-oriented and person-oriented approaches in training programs may promote adaptive teamwork and interprofessional learning. Further research is needed to explore team maturity and its impact on clinical practice.

Background: Small cell lung cancer (SCLC) is a challenging disease to treat due to rapid progression, development of chemoresistance, and discrepancies in outcomes between real-world data and clinical trials. There is a lack of comprehensive analyses in other studies with regard to intermediate events and the treatment process, such as treatment decisions, progression of disease, and the occurrence of adverse events (AEs) over time. Objective: The aim of this study was to apply advanced statistical methods to a longitudinal SCLC dataset in order to identify factors of importance for the risk of AEs and for survival. Methods: Treatment pathways of 421 patients with SCLC collected from Karolinska University Hospital, located in Stockholm, Sweden, between 2016 and 2022, were analyzed with data-driven modeling. The analysis focused on the impact of dose adjustment on AEs, including neutropenia, by estimating odds ratios (ORs) using Bayesian mixed effects modeling. Covariates’ effects on Eastern Cooperative Oncology Group performance status (ECOG PS) deterioration and early discontinuation of chemotherapy with cause-specific hazard ratios (csHR) were explored using competitive risk models. This approach was applied to patient cohorts receiving combinatorial first-line platinum/etoposide and second-line platinum/etoposide or platinum/irinotecan. Results: At the end of the first-line treatment, most patients exhibited tumor regression (n=167). Patients with neutropenia had longer overall survival (hazard ratio 0.70, 95% CI 0.53-0.92). Higher etoposide dose levels were associated with subsequent occurrences of AEs (OR 5.97, 95% CI 1.41-30.5) and neutropenia (OR 3.55, 95% CI 1.03-13.3). Dose adjustment did not affect overall survival if the patient completed the 4-dose regimen treatment. With regard to second-line therapy, fewer patients completed 4 treatment cycles, and the most common reason for early discontinuation was tumor progression (n=72, 58%). Male patients (n=118) experienced fewer AEs and better first-line treatment response compared to females (csHR 0.51, 95% CI 0.25-0.90). High-risk patients (defined as ECOG PS 2‐3 or age >75 years) with early discontinuation of therapy had survival outcomes similar to those who did not receive any therapy. Conclusions: Our results indicate that first-line therapies may benefit from more individualized dosing strategies. It would also be beneficial to assess the risk-benefit of treating specific subgroups, including patients receiving second-line therapy. Real-world data proved beneficial for studying therapy response and risk-benefit of treating patient groups that are underrepresented in clinical trials.

Background: Child-centered care (CCC) is standard practice in pediatrics, emphasizing the child as an individual with rights while acknowledging the child’s role within the family. A key aspect of CCC is the involvement of the child in health care decisions alongside parents and professionals. Although this is a right recognized by the United Nations Convention on the Rights of the Child, it may not always be applied in practice. Objective: The aim of this study is to explore the participation preferences of 3- to 5-year-old children in health care from both their own viewpoint (the child’s perspective) and the viewpoint of their parents and health care professionals. Methods: Q methodology was used to study preferences, comparing responses from 12 children, 14 parents, and 12 health professionals who ranked 25 statements about ways in which children could participate in health care situations. Factor analysis was used to reveal similarities and differences in views on participation preferences. The children’s rankings were also analyzed separately for comparison. Results: Analysis of rankings from children, their parents, and health care professionals identified 3 perspectives with different preferences: direct communication between the child and healthcare professionals; understanding and shared decision-making; and responsive and child-led participation. A separate analysis of children’s rankings resulted in 3 perspectives: being included in and setting their own terms for participation; small choices, meaningful outcomes; and trust through familiarity and shared decision-making. Conclusions: This study suggests that children value shared decision-making and situational control but prefer to leave major decisions to adults. It affirms that preschool-aged children can meaningfully participate in health care when given age-appropriate choices, support, and tools. Children’s perspectives must be acknowledged directly rather than adults assuming their views. The findings support CCC principles and reinforce the United Nations Convention on the Rights of the Child mandate to respect children’s views regarding all issues relevant to them.

Hospitals are complex systems, and the flow of patients is dynamic and nonlinear in such systems. Network representation allows flow algorithms to observe bottlenecks as candidates for optimisation. To model the dynamic behaviour of the patient flow, we need to consider the variability in arrival rates and service times (length of stay). Previously proposed dynamic flow algorithms mainly focused on arrival and departure rates, inflow and outflow, edges' and vertices' capacity, and routing, with applications mainly in transportation and telecommunication. In hospitals, bottlenecks that emerge from the patients' flow are a result of the vertices (wards) behaviour defined by capacity (beds), number of servers (staff), service time variability, and edges (care pathways) distribution probability. We offer a modified flow algorithm that takes a hospital network, iterates over the patients' arrival rates, and measures the flow with respect to vertices' capacities, servers, service time variability, edge capacity, and distribution probability. The result is a dynamic residual graph to measure the bottlenecks' persistency and severity, identify the root causes of bottlenecks, and wards' dynamic nonlinear behaviour. The algorithm provides a quick holistic view of hospital performance and the analysis of the edges and vertices' behaviour over time.

The degree of connectivity among hospital wards and the dynamic nonlinear flow of patients cause bottlenecks to begin in non-priority wards, accumulate within the paths, distribute throughout the hospital, and emerge as overflow in crucial wards. This requires a network-based modeling approach to address the bottlenecks caused by second- and third-order wards and to significantly influence the overall and emergent performance of multiple wards. Understanding the relative merits of different network modeling and analysis approaches in this complex environment is often challenging and requires a holistic strategy to identify persistent bottlenecks and provide evidence-based scenarios. This article introduces a novel hybrid modeling approach that integrates network analysis algorithms and agent-based network simulation of patient flow over a complete hospital network. Through network analysis, such as structural hole and flow algorithms, the approach identifies common persistent bottlenecks from the flow and structural perspectives, while percolation and perturbation analyses measure the performance improvement of wards based on variations in patient flow, and the simulations enable the investigation of scenarios. The results indicate the wards and patient types that can contribute to improving the hospital’s performance. The proposed approach facilitates holistic, dynamic modeling of hospitals, irrespective of their network scale, and enables the identification of bottleneck sources and their associated paths, contributing to a comprehensive assessment of the system’s performance.

Background: Children have a right to express their opinion on all matters concerning them. For children to be seen as actors in healthcare situations, both the child perspective and the child's perspective are needed. Aim: To explore child participation in healthcare from the child's perspective through the following questions: Question 1: What is considered participation in healthcare among children aged 3–12 years? Question 2: What factors hinder and promote child participation in healthcare?. Methods: Systematic review reported following PRISMA guidelines. Database search was conducted in MEDLINE, Cumulative Index to Nursing and Allied Health Literature and Web of Science Core Collection, and 28 studies were included in the review. The data were analysed using interpretive data synthesis. Results: Six themes were identified: Question 1: 1 being able to decide how to act in the situation, 2 communicating with health professionals, 3 being adequately informed, 4 being allowed to make decisions; Question 2: 5 unfamiliar venues, parental obstruction and children's needs not being considered and 6 security, comfort and space. Conclusion: Child participation in healthcare depends on their perception of the situation and opportunities created for their influence. Decision-making on simple practical matters offers meaningful opportunities to acquire and refine decision-making skills and these decisions are therefore developmentally significant. This review identified a gap in knowledge on pre-school-aged children's preferences in participation in healthcare situations. Implications for Care Practices: Children should be recognised as unique individuals and asked about their preferences for participation in healthcare situations. They should be handed over a degree of power, as much as they are able and willing to take. Nurses have a central role in facilitating and encouraging participation by listening to and respecting children's views. Digital communication tools are one way to implement child-centred care and increase children's participation, but more research is needed. Reporting Method: This systematic review was conducted and reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology. Patient or Public Contribution: No Patient or Public Contribution.

Research data management has become an inevitable part of research, and both funding agencies and publishers nowadays require open and reusable data. This article focuses on one of the most prominent initiatives promoting reusability of research data - the FAIR guiding principles - nowadays widely accepted as the new standard for research data management. Through semi-structured interviews, we investigated researchers' experiences of practicing FAIR research data management within the context of a multi-stakeholder project within the field of health research funded by the European Commission. Our analysis showed that the informants' experiences of practicing FAIR research data management differed largely depending on which scientific tradition they belonged to; something that previous studies have attributed to shortcomings in the current infrastructure, lack of resources and persistent cultures around data sharing in the wider scientific community. Drawing on previous work presented within the field of Critical Data Studies (CDS), we argue that our findings point to a more fundamental problem; namely the failure to recognize that the FAIR framework is built on a positivist conceptualization of data. We argue that if FAIR is to have any chance of succeeding in its ambitions to be as inclusive and all-encompassing as it wants to be, these insights need to be taken more into account and provide some potential pathways.