Table 2 Themes, sub-categories, and meaning units/excerpts

 Simulation task efficiency

“When we were just trying out things (box-trainers), I felt it went well and I did great! But as soon as we started timing ourselves, it suddenly went horribly!” (ST10).

“Yes, that made me stressed (the P.O.P-trainer)! Once you start the stopwatch, you’ll just get more stressed.” (ST13).

“It’s a basic task which should be quite simple and straightforward, but then you add the time aspect, which makes it stressful.” (ST14).

“When you have a goal (time requirements), then it automatically becomes a little more interesting.” (ST14).

“I don’t think I did well because I spent a lot of time on the tasks. At first, I couldn’t handle the time pressure and I didn’t manage to fulfil the time requirements right away.” (ST19).

“When I started the stopwatch the first day, I got such an overwhelming feeling of competition, it was really strange, and I just turned up the speed and I performed fast. It was a really encouraging feeling and just fun. It was a very positive experience. But eventually I think the time pressure became very draining, so I stopped timing myself.” (ST20).

“The most stressful simulation training task is the D-box. It’s probably because you are aware of the time requirements; it’s such a narrow time requirement, you are barely within the requirements every time.” (ST4).

“But the time requirements were just… so… the time pressure ruined the whole course for me… he he he…” (ST10).

 Simulation task difficulty

“I think I spent too much time on the parts of the simulation task where I had to suture. I struggled with positioning the needle correctly when I was using the needle holder, so that frustrated me quite a bit. When I felt I had spent too much time on this task, I got a little stressed.” (ST8).

“Those grasper entry holes were really small, and the graspers were of poor quality (laughing), and then they didn’t really act the way I wanted them to! I think the time factor had an impact. As soon as you have to compete against the clock, everything gets worse ...” (ST14).

“The surgical knot was difficult to handle anyways, so when we started timing ourselves, it made me spend even more time getting the knot right… I felt that was stressful!” (ST3).

“I thought the box-trainer was really challenging and it took me a very long time before I managed to crack the code on how to do it… just to figure how to get through the loops without having those awkward choppy movements.” (ST16).

“Yesterday I didn’t do so well so I had to take a little break. I needed to figure out how to do the tasks correctly. I then focused on completing them accurately instead of doing them as fast as I could. The more accurately I performed, the faster I finished the tasks. I felt less stressed when I figured this out.” (ST20).

 Unrealistic haptic feedback and lack of realism in the graphics

“You don’t get the same touch sensation from the VR tissues. You discover the computer image resolution is not that great, because you might think that you grabbed something, but you really didn’t...the VR image is deceiving you a bit.” (ST2).

“Considering what you can get on a regular gaming PC nowadays, comparatively this VR simulator has basic graphics, there is no doubt about that.” (ST14).

“The VR simulator is getting better, but so far the graphics are not sufficiently realistic and the VR operation scene does not perform as it would in real life.” (ST12).

“When the appendix does not want to get into the endo-bag because it does not understand gravity, then the whole thing becomes a bit too unrealistic…Yes, and it fails to mimic crucial things like tissue…” (ST16).

“My experience on the VR simulator is that it is unrealistic. In reality, the operation scene will never look like that. Additionally, I can only perform the procedure the way the simulator directs, and I can only use certain instruments that are predetermined by the computer program; thus, it all feels a bit fake, because those instruments are not the same ones that we use at our workplace.” (ST16).

 Minimal stress related to VR simulation tasks

“It (VR simulator) wasn’t stressful at all, I thought it was fun!” (ST10).

“The issue is that the tissue you are trying to grab does not behave as it would in a real patient; this shatters the illusion of an operation. The failure is due to how the tissue moves and reacts, more so than the overall graphics.” (ST11).

“It’s a lot like in a computer game.” (ST2).

 Impact on motivation

“I think it isn’t sufficiently sophisticated to really challenge you like a proper surgery would. Sure, you work through the steps of a surgical procedure, and you can gain an understanding of where the organs are located. But to be honest, I wouldn’t be bothered to spend a lot of time practicing on a mediocre virtual reality experience.” (ST5).

“I always exceeded the time requirements slightly. Maybe it’s because it didn’t feel very realistic, it felt more like a game.” (ST19).

 Low technical performance

“I felt stressed and frustrated when training on the D-box, because in the beginning I struggled with the technique and to achieve the results I felt I should have obtained. So, I became quite frustrated, which caused me to perform worse and then I got even more stressed, and it became a downward spiral.” (ST8).

“I felt that I didn’t handle the technicalities so well (on box-trainers).” (ST15).

“It was challenging (laparoscopic knot-tying), I spent a long time without realizing what I was doing wrong, and that was very frustrating. It just didn’t work! It was tough when I felt I had tried really hard and still did not complete the task requirements. I tried everything the instructors suggested, and it still didn’t work, and then I began to get tired, and it all became even more difficult.” (ST19).

 Inconsistent performance

“I’m frustrated that the instrument and the thread (of the D-box) do not move in the direction I want them to! It’s frustrating that sometimes it works for me, while other times it doesn’t; it’s hard to figure out what you do correctly or why you are failing at something.” (ST2).

“Yes, I’m stressed, I am actually doubting if I will master the requirements even though I have trained a lot on box-trainers previously. I’ve not had the opportunity to practice at my hospital recently, as all the box-trainers there are broken. It’s a specific simulation task. I’m sure that if you have not been able to practice prior to the course it’s difficult to meet the requirements. Obviously, it helps to do specific training.” (ST20).

 Lack of laparoscopic training

“The simulation tasks stressed me because I’ve never tried this kind of simulator (VR simulator) before. I’ve not performed much surgery yet, and suddenly I had to deal with anatomy too, and it was excruciating because I was so scared of doing something wrong. In a real surgery I would have required very detailed guidance throughout the procedure.” (ST20).

“At our workplace, it is very uncommon for senior surgeons to suture laparoscopically, and for surgical trainees to do that, it just doesn’t happen.” (ST9).

“I have not sutured laparoscopically prior to this course, so the P.O.P-trainer was a little challenging.” (ST14).

“I spent a lot of time at the start of the training session just figuring out how to change the equipment and other stuff.” (ST1).

“I was a bit annoyed with the appendectomy, because it is a procedure I don’t have much experience with, and I also got a little frustrated because I realized while I’m doing the simulation task that this is probably not how it is done in a real surgery.” (ST6).

 Self-imposed pressures

“No, yes, I was frustrated and annoyed by how bad I performed just now… I managed to finish under two minutes a couple of times, but now I relapsed completely to my starting levels again, timewise.” (ST9).

“As soon as we started with the training, even without timing the task, I was already stressed.” (ST13).

“I was slow in the beginning and that was stressful. You also stress the moment you start trying to beat your own times.” (ST15).

“Yes, you put pressure on yourself and then it becomes more stressful.” (ST18).

“I felt that I did better yesterday, but now it is getting worse and I felt more stressed…” (ST15).

“I consider myself as a pragmatic person; I expected to perform well on these tasks, and I managed to master the tasks quite fast, but all of the sudden I started to get really stressed.” (ST20).

“It’s so intense, you want to beat your own record, and when that doesn’t happen, you become overwhelmed… but I did not perceive the situation as stressful; tense is more befitting.” (ST13).

 Socio-evaluative threat

“I’m stressing with the time requirements. I want to keep improving my results. This D-box is a classic throughout the country, just about every hospital has one. So, I want to achieve excellent results.” (ST4).

“Today has been stressful, because we tried to break our personal records and then the instructors came to observe when it was going pretty well, and then all of the sudden it went downhill…” (ST15).

“I expected more from myself on the P.O.P-trainer because it simulates exactly what I should master in a real work situation.” (ST20).

“I noticed that I became stressed when I realized I was slower than the person next to me. I was quite displeased, while thinking his results were a little undeserving (laughing). I noticed how easy the simulation task was for him, so I became really consumed with comparing myself to him.” (ST20).

“It’s rather stress from the environment and the circumstances that affects me, more so than the simulation exercise itself.” (ST13).

“I don’t like the time pressure, I’m not really a competitive person.” (ST1).

“I stress myself; I do well with communication but I’m bad at practical stuff.” (ST13).