Analysis yielded four main themes: ‘nervous anticipation’, ‘shock and awe’, ‘in the moment: Flowing and buffeting with the emotions’ and ‘safe landing?’.
In the time period leading up to the actual simulation, a range of particular emotions were experienced by participants. Emotions could be evoked even prior to arriving in the simulation venue.
“I felt anxious…the weekend before the simulation, I could not sleep while thinking about the simulation…I had A stomachache before I came here, I felt bad.” [John]
In this preparatory phase, anticipation dominated participant’s emotional experiences. The emotion of anticipation was often held in tension between being a negative and positive experience. It appeared greater propensity to have a more negative experience, being associated with emotions such as fear and anxiety.
“I felt a lot of anxiety, I wanted to know what kind of patients I would have to attend and if I was going to be able to handle them or not… for me stress and anxiety stimulate my learning if it is not excessive, for example increases my ability to concentrate” [Peter]
Central to these emotional experiences, where participants’ perception of uncertainty; uncertainty about what they were about to experience and uncertainty of how well they would perform. Such experiences triggered with some participants to question their professional ability, both from their own perspective and what might others perceive (i.e. fellow students and faculty). Often, they experienced a mismatch between their perceived ability and the expected by the faculty. However, such experiences, including the fear of failing, had potential to promote participants to concentrate on their learning and perform to the best of their ability.
“I felt anxiety in front of the unknown and I clearly believe that this emotion is super positive for my learning as it predisposes my mind to receive information, process it and make decisions.” [Alex]
Shock and awe
Moving from the pre-simulation to the intra-simulation phase marked an important transition in the emotions experienced by participants. As they entered the simulation-suite from the briefing area, an array of intense emotions was induced. Often participants felt overwhelmed with the multiple stimuli and cues they encountered, ranging from the presence of various individuals, clinical equipment, noises and various artefacts. Participants’ point of view video footage would often swing rapidly from side to side (reflecting their head movements) as they started to scope the simulation environment. Participants often felt emotions of anxiousness, describing features of stress and hypervigilance. Such visceral and intense experiences had potential to hinder any learning at that time. The vastness of possibilities, and wide ranging sensory stimuli, often mediated participants to feel overwhelmed; leaving them grappling to make sense of what lay ahead for them in the WRS.
“When I started, I felt impacted, surprised, it was too much…. I did not know who was more serious than the other…” [Mark]
Such intense negative emotions began to reduce when participants started to assimilate and orientate themselves to the scenario. In doing so, participants began to consider where best to focus their attention. Engaging with key individuals in the simulation enabled them to direct their efforts and accommodate more to the situation; selectively orienting themselves to key materials (e.g. clinical observation changes) and social (e.g. nursing staff) dynamics within the simulation. Attuning to the complex dynamics within the simulation gave participants a greater sense of control in their learning and reducing their negative emotions.
“When I entered, I felt initially disoriented, I saw so much to do and did not know how to start, but once the time passed I began to feel a little more confident and I felt a little more free that I could do what I thought was right …” [Ann]
In the moment: flowing and buffeting with the emotions
As the WRS unfolded, participants experienced a diverse range of emotions. Both the contextual demands within the simulation and how participants perceived their performance to meet these demands had potential to mediate their emotional experiences. Whilst more negative emotions were experienced (e.g. fear and anxiety), the simulation could also evoke more positive emotions such as pride, eagerness and satisfaction.
“With the first patient I felt calm because I already had the whole scheme in my head of how to treat it, but when I saw the second patient, and I heard the patient complain, I did not know what to do, I was confused, anxious…” [Alex]
As participants progressed in the WRS, they became more attuned to their own perceived notion of how well, or not, they were performing. They drew upon their self-sense of achievement and also any clues provided to them during the WRS (for example if a patient responded to their treatment). If participants sensed a more positive outcome because of their actions, they felt rewarded. Such a dynamic had potential of promoting more positive emotions and improving their confidence for learning in the next stages of the simulation.
“When I saw the ST segment elevation in the ECG I felt calm… I knew what to do…this give me confidence in my knowledge, in knowing that I am doing the right thing and that the patient improved, I will remember this when I am seeing a real patient with a similar history” [Mark]
If participants perceived their progression in the simulation to be less than satisfactory, this could induce more negative emotional experiences such as frustration and embarrassment. In such occasions, participants experienced feeling more scrutinised and fearful of being judged as incompetent. Experiencing such negative emotions had the potential of negatively affecting their confidence. Even if they subsequently perceived themselves to have had a positive achievement in the WRS, such negative emotions could persist throughout the simulation. Depending on the degree of such negative emotional experiences, participants could be spurred on to draw upon this experience and develop their learning.
“I felt insecure because I did not remember the doses... I felt a little disappointed of myself…. it motivated me to study, then do it again and see how I am improving!” [Mary]
In more extreme circumstances, participants experienced despair. In such situations, they were less likely to recall or transfer their knowledge into actions. Participants could experience being paralysed in-the-moment, which hindered their learning. This could create a negative-loop through affecting their subsequent performance in the WRS. If this occurred, participants tried to suppress any outward signs of these negative emotions to faculty and others. However, internally these negative emotions were prominent.
“…Even after examining her, I felt confused, I did not know what she had and I did not know what to do.... but at that moment, this was negative for my performance, I was as blocked, my mind went blank, I did not know what else to do and I just keeping trying to keep going.” [Susan]
Following the simulation, participants often experienced a change in their emotional state. In this post-simulation phase, participants transitioned from ‘performing’ to now ‘being’ a student wanting to develop his/her learning. Often, participants experienced relief that the simulation had concluded. As participants assimilated their actions, they began to judge if they had performed well or not. If they felt that they had performed well, participants would experience more positive emotions such as pride, joy and satisfaction. Such emotions promoted their self-esteem and confidence in their learning. Equally the simulation debrief would further enhance these positive emotions and promote their learning.
“I felt joy, pride in myself, of doing things well because I feel that I have worked so hard to be here … during debriefing I could reaffirm that I know, that I have the knowledge and skills to face real patients in the near future. I felt much more positive emotions that reaffirm me that I know and that promote my learning” [John]
When participants perceived that their performance was suboptimal, this could reinforce and evoke further negative emotions such as frustration and shame. The debriefing had potential to reduce such negative emotions and promote learning.
When the simulation finished I felt relief, I had a little stress. When you showed me that I had failed to examine the patients, I felt shame and guilt because it is something that I should have done well… In the debriefing I felt confident, calm and I took a lot of positive things for improving [Carol]
On occasions, if the negative emotions were intense, this could hinder any sense of learning, even despite the best efforts of the debrief process.