Eight participants took part in the study generating 63 min of video footage and 311 min of interview data. Detailed analysis of the verbatim transcripts of these interviews yielded four main themes: (1) ‘Authentic on all levels?’, (2) ‘Letting the emotions flow’, (3) ‘Ethical alarm bells’ and (4) ‘Voices of children and ghosts’. Consistent with a phenomenological approach, we have given equal weight to each participant’s experience and therefore have not quantified in the text the number of participants reporting a particular phenomenon.
Authentic on all levels?
Whether the SBL was perceived as being authentic varied in time and with situation. Participants recounted the SBL activity as feeling both true to life, yet at the same time recognising its artificial nature—‘a nice touch’:
It was the fact that there was other things going on as well there were people walking around you could see, you know you were looking about seeing and noticing that there were different things going on. It wasn’t as if people were just waiting for you to come it felt as though that was a nice touch. [Craig]
Participants toggled between reality and simulation as the scenario unfolded and situations and emotions became more complex. The tone and paralanguage of those interviewed became more intense and colloquial when describing stressful or emotionally laden moments. During these times in the SBL exercise, participants reminded themselves they were in a simulation in order to control these emotions.
Participants in the SBL environment discussed how they attempted to keep simulation ‘as real as possible’. The researchers’ explicit attempts at creating realism through the use of reality cues, such as being interrupted to complete patient discharge documentation, were recognised as such and paradoxically became fiction cues:
Since I knew it was a simulation I felt it was almost a deliberate distractor so I said to the nurse I would be there in a minute and I would deal with this first. [Duncan]
However, uncertainties in the environment, such as the identity of other individuals, drew participants into an internal dialogue in which they tried to deduce what was happening based on information gathered. Participants reported this as reinforcing their perception of dealing with a true to life situation, even though in their thinking they acknowledged, at points throughout the exercise, its simulated nature.
There were potential real-world implications of making an error in the medication prescription chart (kardex).
I: Simulator environment – did you feel safe?
I: Did you feel that you could have harmed anybody or did you feel you maybe over-took risks
P: I felt as though if I had been left to write the kardex, I mean, I was worried in case I might have made a mistake, and was, like, you know you were aware that ok, it’s simulation but at the same time, you know if I did make a mistake, someone probably would have picked up on it and would have called me up on it and the situation would have changed… [Craig]
Craig illustrates that the SBL experience can be authentic on different levels, but not necessarily at the same time and in the same way. He felt the reality of worrying about the patient safety aspects of an incorrect prescription on the medication chart (kardex). Yet, he gained a measure of psychological safety in knowing the exercise was a simulation. A further psychological safety net is Craig's belief, when imagining (cf ‘at the same time') if this were not a simulation, that a real-life mistake would have been ‘picked up on’. In this case, both his own safety and that of the patient would be maintained.
Alongside participants’ authentic experiences were a range of physiological responses to increased stress. These included ‘warmth’, ‘sweating’, a ‘fight or flight’ response, an ‘adrenaline’ rush, ‘heart going a dinger’ and a distorted perception of time. Some of these were quantitatively expressed with resolution of difficulties leading to a ‘dipping’ in anxiety ‘levels’. Despite uncertainties and anxieties in the scenarios, all participants felt safe to explore the boundaries of ethical practice in the SBL setting. Whilst participants recognised the potential real-world implications of error, being able to recall this was a simulation provided a psychological safety net that errors would not result in actual harm. Additionally, though participants had been briefed that they could withdraw from the SBL exercise at any time, none chose to exercise this option. Whilst participants felt ‘pushed’, none were pressed beyond their tolerable limits. All commented that they would like to re-engage with similar SBL scenarios at a later date, articulating a greater confidence in handling them.
Letting the emotions flow
Emotions featured prominently in participants’ interviews, and each recalled unpleasant negative feelings such as fear, anxiety, awkwardness, loneliness and regret, through to embarrassment and feeling silly. Less often, more positive feelings of humour and relief were present. All participants had to navigate a rapidly shifting emotional landscape as the scenario unfolded.
Strategies for dealing with intense high-arousal emotions by suppression and refocusing were described. For example, allowances were made for a patient’s inappropriate remarks by rationalising these as arising from his medical condition or cultural background. Sublimation of strong emotion into concentrating on the correct performance of a technical task helped maintain control. The emotional colouring of a situation could subtly vary, and this is instanced in the desire of participants to escape from the arguing relatives during the end-of-life scenario. An initial response of ‘getting out of there to get help’ becomes a desire to leave to find a consultant in order to then return with that senior presence to achieve emotional resolution. Participants were able to refashion their primitive visceral responses—the flight response of ‘getting out of there’, into constructive strategies—leaving to find help. Despite incomplete resolution of an ethical dilemma, Duncan experienced a sense of emotional fulfilment when some of the underlying tension was defused. He had done all he could to try and resolve a disagreement between a patient’s relatives. Even though there was no complete resolution, he had reassured them, and he viewed this positively:
At this point I was actually feeling pretty good em, I felt at the end there was a bit of resolution to the scenario…obviously they were still arguing when I left, but I felt that I had reassured them both and that there was a clear plan from here…I did feel a sense of closure and did feel satisfied… [Duncan]
The role of previous life experiences assisted in real-time processing of feelings. Drawing on similar experiences of encountering inappropriate behaviour, participants were primed with a repertoire of coping strategies such as maintaining distance and being ‘very professional, nice and pleasant’. This permitted them to regulate their feelings of awkwardness.
Ethical alarm bells
Participants readily perceived the explicit ethical dilemmas relating to autonomy and confidentiality present within the two SBL scenarios. Recognising the implicit ethical considerations for truth-telling and raising concerns when confronted with an unprofessional nursing colleague in the ‘maintaining professional boundaries’ scenario was more challenging for some. Of interest were further, emergent ethical dimensions. A urinalysis specimen bottle was unintentionally mislabelled during one iteration of the above scenario. This was recognised by the participant who resolutely refused to accept the validity of the results and insisted on such to the simulated nurse.
‘Alarm bells’ rang when ethical boundaries were crossed. Trigger phrases such as ‘Facebook’, or obvious transgressions of confidentiality in both scenarios, empowered the students to take action. Robust moral courage was displayed when refusing to give credence to results from incorrectly labelled specimens despite repeated reassurance or persistent ‘seductive’ attempts to solicit patient information for uploading to Facebook. Moral courage is ‘the individual’s capacity to overcome fear and stand up for his or her core values’ [31]. It is the willingness to speak out and do which is right in the face of forces that would lead a person to act in some other way. Such moral courage was displayed by taking refuge in the tenets of ethical principles:
…. that was my only way to get out of this was to throw in that word and hope she doesn’t push on further after that cos I would just have to keep repeating patient-doctor confidentiality, patient-doctor confidentiality. [Jaya]
There was less clarity when other ethical boundaries were approached. The specific legal status of the advance directive in the ‘end-of-life care’ scenario was unknown by participants. Duncan felt an unease ‘at the back of [his] mind’ when discussing confidential patient information with a person who ‘appeared to be a nice guy’ at the relative’s bedside. The smiling and supportive nurse made it more difficult for participants to challenge her unprofessional behaviour. Cheryl tells a falsehood about not having a Facebook page when asked by the nurse, describing subsequent regret she told a lie when viewing the PoV footage (see Additional file 2). Others displayed avoidant behaviour by not rebutting the nurse’s insistence that it was ‘ok’ to post patient-identifiable comments on social media.
The approach of these ethical boundaries could be masked by ignorance of the legislative backgrounds in one case and the context-dependent nature in which they arose. In the latter cases, a friendly person or smiling face disguised the request to compromise confidentiality and subsequently made it more difficult for participants to challenge unprofessional behaviour.
Voices of children and ghosts
Participants used the phrase ‘first day’ when describing the progression from medical student to a Foundation Programme Year 1 (F1) doctor. Accompanying the transition into this new environment and culture are residual tensions and concerns derived from undergraduate experience. Some felt unable to raise concerns or make suggestions due to their inexperience. Students have an insubstantial presence on the wards; they feel like ‘ghosts’; they cannot fully enter into what is happening and ‘soak up the anxiety’. They are like ‘little children who should be seen and not heard’. They are a nuisance or inconvenience if they did speak up; senior staff have ‘a right’ to get annoyed with junior staff by virtue of their position on the medical hierarchy.
Em, cos, well I know I was being an F1 but as a medical student whenever I go to the hospitals it always feels like, we’re in the way of doctors and nurses like, this is their job whereas we are technically still not qualified and so even if we see something that’s not right or what not like I feel we can’t really voice our opinions, cos if we do we’ll be like those whistleblowers kind of thing and then they’ll be thinking like we’re just medical students how can you pass these comments, you know we’ve been working here for years and you know what’s right kind of stuff, so that’s why I always feel inferior to doctors and the nurses working, and I know it’s wrong and I should probably just voice it out saying I’m going to be part of the team but I guess because of their years of experience wise I always just tend to clam up and not say anything. [Jaya]
Participants described anxiety at the presence of a consultant in the scenario. This inhibited their performance of the urinalysis as they were worried about being asked something they did not know. Descriptions of ward attachments in which the participants suggested some areas for improvement that were not taken seriously reinforced a passive and disempowering stance towards the workplace. These feelings of passivity spill over into how interprofessional relationships with nursing staff are viewed. Nursing staff have to be ‘appeased’, they can ‘make or break’ a junior doctor’s working life and one has to be ‘careful’ when dealing with the nurses. An example of nursing staff gossiping about another student went unaddressed by one participant who avoided challenging or reporting unprofessional behaviour. Another recounted being shouted at by a theatre nurse and the negative effect this had on their views of nurses more generally.