This study used an explanatory sequential mixed method design14 in order to answer the research questions. The emotions experienced during the exercise were studied through the achievement emotions questionnaire (AEQ) Spanish version15 and students’ performance in WRS were rated using the Postgraduate Ward Round Simulation assessment tool (PgWRS)16. Focus groups were conducted to provide a deeper understanding of the role of these emotions on their learning process. The Reporting Guidelines for Health Care Simulation Research were used.17
The study was carried out in the Clinical Simulation Center at Universidad Católica del Norte, Chile. The medical degree program lasts 7 years. Students start clinical practice in year 3.The last 2 years correspond to internships where students are enrolled in emergency ward round as part of their medical training. At this stage of training, students are expect to be able to clinically assess patients, provide a provisional diagnosis, determine a management plan and develop their ward based skills. Students have clinical exposure and simulation-based learning activities throughout the curriculum. Between 50 and 65 students annually enroll in the program.
Each participant took part in an emergency ward round simulation. Characteristics of WRS consist of complex clinical scenarios situated in a simulated clinical ward that involves multiple elements such as managing more than one patient, interacting with relatives and other healthcare professionals, and dealing with multiple competing tasks activities where interruptions and distractions occur. 3,18-20
Briefing was conducted in order to orientate participants before the simulation. During the WRS, each participant was involved on a “hand over” exercise for 25 minutes followed by a 45 minutes debriefing using a “Debriefing with good judgment” approach 21. This approach utilizes a self-reflection process that helps students recognize and resolve clinical and behavioral dilemmas raised by the simulation itself and the instructor. This supports the participant to critically reflect on their emotions, actions and how they could modify future performance.
In this emergency simulated ward, participants had to attend 4 simulated patients, two of them were accompanied by relatives. Situations with different emotional grades into scenarios were promoted: 1) a patient being very grateful after being treated for a supraventricular tachycardia (a form of heart arrhythmia); 2) family conflict regarding the cardiorespiratory arrest (secondary to asphyxia) in an infant 3) an unconscious patient brought to the emergency room by a healthcare provider after a motor vehicle accident and 4) a patient who is having a miscarriage.
A qualified nurse was part of the scenarios as well as a doctor from the staff who received the patients at the change of shift after they were taken care by the participants. Each role player had to adhere to scenario scripts that guided their performance and roles in the scenarios. They were trained by one of the researchers (CP) who has experience in training simulated patients. During the briefing, each participant was asked to consider the activity as if it was their first day as a ‘junior doctor’ working in a clinical ward. The task was to gain an overview of the patients’ cases, related patient files and patient medication charts. They had to define consultation goals, conduct the ward round and re-evaluate the patients’ therapy.
Recruitment and sampling
For this study, all 6th year medical students (n=55) were invited by email to participate in the study. Students had some prior experience of simulation-based learning activities, but this was the first time they faced a WRS exercise.
This study received approval from the Research Ethics Committee of Universidad Católica del Norte (F.M: 82-2017) and informed written consent was obtained from all the participants.
Quantitative data collection and analysis
Achievement Emotions Questionnaire (AEQ)
AEQ is a multidimensional self-report instrument developed to measure the emotions of students in academic situations and was used to identify students´ achievement emotions before, during and after simulation 22-24. The Spanish version 15 was applied immediately after debriefing (appendix A). This questionnaire includes 68 items that measure eight emotions: enjoyment, hope, pride, anger, anxiety, shame, hopelessness, and boredom. Students rate their emotional experiences on a five point Likert scale from ‘strongly disagree’ (1) – ‘strongly agree’ (5). A score of 4 or higher was considered high/good, between 2 and 3 quite neutral and 2 or less, low.
Postgraduate Ward Round Simulation Assessment Tool (PgWRS)
A validated Postgraduate Ward Round Simulation assessment tool (PgWRS)3, 16 was used to rate participants’ performances (Appendix B).
This tool assesses 9 domains: Task management, clinical skills, acutely ill patients, prescribing techniques, response to interruptions, written documentation, communication, health and safety and professionalism. For each domain, a five-point Likert scale was used to assess domain performance, ranging from ‘1’ (very poor performance) to ‘5’ (outstanding performance). Because of the length of the exercise, written documentation was not assessed. A score of 4 or higher was considered good performance, between 2 and 3 regular performance, need to improve and 2 or less, low performance.
All simulation sessions were video recorded. Video recordings were viewed by two independent raters who were experienced medical doctors and educators and have received training in using PgWRS. Thirty five out of fifty-three participants (66%) were scored by the second rater. Ratings of the two observers had a high correlation (r = 0.792, p < 0.001).
Descriptive statistics were calculated and AEQ scores were averaged. The Cronbach’s alpha’s of the Emotion indexes were calculated. Performance assessment scores were summarized and correlated with the AEQ scores using Pearson coefficient. SPSS version 23 was used for the calculations.
Qualitative data collection and analysis: Focus groups
After the simulation exercise, all participants took part in six different focus groups of 8-9 medical students. The focus groups were carried out in order to provide a deeper understanding of how medical students describe their emotional experiences during the WRS and the impact of these emotions on their learning. One author (CBP) facilitated the focus groups. Each focus group lasted between 35 and 45 minutes. Questions addressed students’ emotions during simulation and the role of such emotions in their learning process. (The interview guide is available in Appendix C). Focus group interviews were audio-recorded and transcribed verbatim.
Template analysis approach for the data analysis was used 25. A succession of coding templates consisting of hierarchically structured themes was carried out and iteratively applied to the data. The themes were modified continuously as the analysis progressed. To start with, the research anticipated some themes to be identified in the analysis. One author and a research assistant independently coded 2 focus group transcripts. The research team discussed and reviewed the emergent themes based on importance and relevance to the study. Final agreement was achieved on themes. After the agreement, the initial coding template was developed and applied to all focus group transcripts. The research team met regularly during the study to discuss the analysis.