The characteristics of student engagement in the simulation-based learning environment were summarized into three types: reflective engagement, performance engagement and interactive engagement. Furthermore, sub-themes were also identified as described below.
Reflective engagement with the purpose of problem solving and active thinking engagement
Active, persistent, and focused thinking engagement
One of the most significant features of cognitive performance in a simulation-based learning environment is “active reflective engagement”. Many students emphasized in the interviews that this is a kind of active thinking and active engagement.
“Everyone knows what they want to do, what tasks they have to accomplish, and how they can cooperate with others. In this way, our way of thinking dedicates towards what we take the initiative to think about, what we want to do. We also take the initiative to complete our own tasks, start proactive communication and cooperation with others. In this sense, everyone’s way of thinking has become more active.” [W1]
Different from the short-term thinking in traditional class, the simulation-based learning environment requires constant and persistent thinking. Another frequently used word is “focus”. For students who were highly focused in a simulation-based learning environment, they were deemed to have a “strong and attractive energy field” [L1]
“[In traditional classrooms] Sometimes students are asked some questions but given limited time for a response. Many times, the class continues without giving enough time for student’s reflection on the questions.” [L1]
“[In a simulation-based learning environment] If you don’t take time to think about it, the patient in front of you may die, and you will feel a strong sense of guilt ... if you don’t solve the problem, things won’t work out. I will try my best to do it, not to give up halfway ... unlike in a traditional classroom, when the teacher asks a question, you just need to give a standard answer and it all ends.” [H1]
The simulation-based learning environment also allows students to be more focused on listening to the lecturer. You should take the lesson seriously, because the follow-up session contains real-life practices.
“In traditional classrooms, sometimes the teacher talks too fast, and you will feel a bit unwilling to listen ... the possibility of being distracted is very little, you can focus more on the teacher, and you can take more notes.” [W2]
“In order not to make mistakes in front of everyone, you have to listen to the teacher more seriously. Therefore, students are more motivated to learn.” [H2]
Problem-oriented thinking engagement
Students must have familiarized themselves with the knowledge before entering the simulation-based learning environment. This is different from the passive learning practices in traditional classrooms where students just follow the teacher’s thinking. Instead, it is a re-understanding of the original learning process and outcomes. Students are able to experience the process of self-knowledge construction through observation, reflection, practices as well as problems-discovery and resolutions. Problem solving is the driving force of thinking activities, and the thinking process is reflected in the process of problem solving.
“I feel more self-driven to solve the problems if they come up. I do not rely on teachers to guide me to solve the problem. After all, I cannot just leave the problem there without doing anything… what is more important is the way of thinking. That is, how to find problems and how to find better ways to solve problems.” [H1]
Problem-solving reflective engagement is accompanied by close connections between knowledge. Because it solves real-life problems, the knowledge being connected is situated in a multidisciplinary context and the voices of the patients are also being heard.
“In traditional classrooms, you normally passively accept some knowledge. Unlike this [simulation] lesson, you can take the initiative to talk about it ... in a normal session of your major, you just passively accept theoretical knowledge. You would not evaluate doctor-patient relationship from multiple perspectives, such as the potential influence over society and a humanistic perspective. I think my way of thinking has become more active.” [Y1]
The process of problem solving is usually accompanied by communication and mutual affirmation among peers. After questions and thinking are valued, students are more motivated to think actively.
“If you have your own thinking and vocalize it, everyone will listen more carefully to your suggestions, and then put forward their own views ... your own thinking is built up or challenged by others, which pushes you to do more active thinking.” [L1]
Active “voice” in class
“Speaking” in the classroom is another important manifestation of reflective engagement. On one hand, an individual has more opportunities to ask constructive questions.
“When the student listens to the lecturer very carefully and asks questions; or when analyzing the case, the student can politely interrupt others in a timely manner, and give their own opinion ... especially when the questions they ask are constructive, or if they really facilitate others to think more about the questions. ” [L1]
On the other hand, unlike the commonly seen shyness and silence among East Asians , in a simulation-based learning environment, students are more willing to actively engage in conservations and answer questions raised by peers.
“I am more involved than usual in [simulation] class. In traditional classrooms, students just sit in class and dare not answer teachers’ questions. And now [in simulation class], if your peer asks you questions, you can quickly give a response. Since if no one knows the answer, the game will not continue. The teacher usually asks questions in class. The class gets embarrassing if no one speaks ... [in simulation class] I feel the need to talk about it myself, whereas there is no such feeling in [traditional] class.” [H2]
When it comes to the reason why students want to speak up more in a simulation class, many students think that “because of the group-discussion format, the group activities ease the classroom tension, which makes you more relaxed and can stimulate your thinking.” [Y1]
Many students also admit that this spontaneous and self-driven engagement stems from the novel teaching mode.
“First of all, we would not be sleepy, because we usually have a lot of academic stress, especially during the exam month. Under such circumstances, this new teaching mode allows us to be more engaged and focused in the classroom. Secondly, this novel learning mode allows us to understand some relevant knowledge better as it spurs us to combine theory with practice when evaluating problems.” [Y1]
Performance engagement characterized by strong emotional expression and leadership
Strong emotional experience and disclosure
Learning in a simulation-based learning environment usually requires medical students to play different roles, such as doctors, nurses, patients, and family members. Through these exercises, the students are expected to be familiar with different roles and therefore achieve the learning goals. Therefore, they often claim to be students from “a certain performing university” or “a performance major”. “Acting Elf” often refers to those who are particularly good at acting.
Performance means that it is necessary to channel emotions into the character and act out the character’s behaviors. The current study found that strong emotional experience and disclosure is an important manifestation of performance engagement.
“As far as I observe, the extent of student participation is diverse. Some people are more active to participate, while some individuals are indifferent to emotional performance if they don’t pay much attention to this course.” [W1]
The emotions in the simulation-based learning environment change in accordance with the progress of problem resolution and are most associated with the outcome of the patient. There could be “unconsciousness, excitement, tension, eagerness, expectation” when the situation of the “patient” is unknown; there could be “happy feeling, confidence, excitement and sense of fulfillment” if the operation is successful; there could also be “regret, discomfort, guilt, inferiority, depression, depression and feeling lost, unconvinced or even condemned” when the operation fails.
It is the strong emotional engagement that enables students to be physically and psychologically involved in the learning activities, contributing towards a state of “presence”.
“That kind of atmosphere is different [in a simulation environment]. The physical environment and learning atmosphere affect my psychological state and make me more focused on being involved in the task. I do not feel like just physically being in a classroom while mentally distracted by something else.” [H1]
Many students even enter a state of “flow” when they fully immerse themselves in the tasks.
“In the laboratory, I don’t care too much about how long the course takes. I think even if this class overruns, I won’t be too bothered.” [H2]
Emotions and feelings are attitudinal experiences stimulated by the sense of “need”, revealed through behavioral outcomes. Although emotions and feelings are inspired by objective experiences, their nature is determined by people’s perception of the situation . During the interview, some students compared the emotions that were more “calm” in traditional classrooms with those that were “fuller” in the simulation-based learning environment. Compared with the traditional classroom atmosphere, which suppresses the expression of emotions, a more relaxing simulation-based learning environment helps release various emotions.
“Generally, in the classroom, because everyone is listening to the teacher to gain knowledge, the atmosphere is more serious. Even if we have some emotions, we will not express them. Everyone remains calm and does not respond much. But when we perform a live simulation in the laboratory, first of all, there is a sense of tension. You have to complete the tasks given by the teacher. You don’t know if you can do it well. Second, when we engage in this work, we can easily reveal our emotions regarding whether the work progresses well, whether the result is good, and what has happened in the process. For example, if something goes wrong or when we make a mistake, we will be very anxious, there may be a sense of shyness and even shame. In short, our moods are fully revealed.” [W1]
Demonstration of professional leadership
The simulation-based learning environment usually creates a realistic hospital scene. In this atmosphere, there are many actions that reflect professional leadership. These include whether one can take the initiative to take the responsibility of the leader, whether one can lead the team to facilitate the learning process, or actively follow the leader, quickly adjust to their role, analyze the problems, and offer responses. A deeper level of participation is reflected when those “leaders” use their knowledge and demonstrate their capabilities. As some participants said,
“Some people will take the responsibility of leadership voluntarily and spontaneously assign people to do certain things. If someone volunteers to lead, I will consider that person very devoted and motivated. For those who follow the lead, I also think that they are thinking deeply and engaged entirely”. [L1]
“When the leader is directing the group, the leader will do their job meticulously. This includes how many people should be allocated to every activity and what every member should do... when the leader organizes everything very thoroughly, I could tell that the leader was very engaged at that time.” [W1]
Interactive engagement as a result of multidimensional interactions between learners, learning communities and the environment
Interaction with realistic learning situations
The most prominent feature of the interactive learning environment is the realistic working session, including mimicking the busy atmosphere as well as the vivid “doctor-patient” interactions in a physical hospital setup, which enable students to be fully drawn to the learning context.
“The more realistic the environment is, the stronger feeling I could have that similar situations would happen in real life practices.” [K1]
“At the time, the assessment involved a little baby [model] ... we played with him, and we felt a kind of attachment. We would say, ‘look at those babies’. There would be a kind of motherly love – a kind of feeling expressed spontaneously.” [L1]
“Children can survive by double-compression. I feel that I have to do a good job ... and then I would carefully read the materials given by the teacher, and then delve deeper into the textbooks. I want to successfully rescue the baby ... because the baby would cry disparagingly, that would make the atmosphere very intense ... and then the sense of urgency in that situation is much stronger than the pressure imposed by teachers or exams in reality.” [H2]
The professional responsibility of medical students is also stimulated by the simulated medical environment that fully brings the medical students into their professions.
“For example, if you rescue the senior simulator successfully, it will give out some responses. For example, during the rescue, the student can monitor the “patient’s” pulses, blood pressure etc. ... in that simulated context, because of the role you play, you will develop a strong sense of responsibility and want to do it well.” [H2]
“I will subconsciously think that I am a professional and I can do this well. Then, I will not be distracted by others since I just need to do the operation based on what I have learnt. Building on that, I will also think about how I can better use the knowledge.” [H2]
This sense of professional responsibility also motivates students to achieve a higher level of engagement.
“I'm probably more engaged at that time [in the simulated learning environment] than I would be if I were alone. That is, when someone wants to interact with you, it makes me feel that this is not my own business. It is not like normal practice which is solely operated by a single student, which easily makes one lonely and bored. Because there are interactions in a strongly collaborative atmosphere, which promotes my sense of responsibility. That is, if I do it wrong, my teammates will have to bear the consequences too, so it is not my own business.” [H3]
Support from teammates
Peer interaction is mainly manifested in the sharing of information, mutual discussion, and skill guidance required in the process of problem solving.
“You exchange views with your peer ... and jointly solve this problem, which leads to increasing peer support.” [K1]
Unlike ordinary peer communication, in the simulation-based learning environment, peers are more conscious and conduct more in-depth communication within the profession, and develop the ability to think about problems holistically.
“What are their [my peers’] concerns? What are my concerns? What are the similarities and differences between my peers’ and my own concerns?” [H1]
The “companion” in the simulation-based learning environment is not simply a learning partner, but a buddy who needs to complete a task that is very challenging. The mutually facilitative interaction between peers promotes active engagement. However, if the interaction is not harmonious, it will hinder further engagement. Attention and responsiveness from peers will drive the next round of positive emotional experience and student engagement.
“If everyone is very cooperative and actively participates, the interactions would be smoother, it will have a more positive effect on participation. If everyone is cold and everyone does not want to talk, then this task cannot carry on.” [H3]
“In order to complete a group task, we need mutual encouragement and support. I feel that someone is listening and someone is willing to respond to you. This sense of mutuality is very fulfilling and very encouraging.” [W2]
The impressive performance of other students in the process of peer interaction will also motivate the students themselves to be more engaged.
“During interaction, I can feel the kind of enthusiasm of the classmates. They are motivated to do the task, because they really value the patient and imagine what if the same experience should happen to themselves.” [H3]
“The students who participated in that course are very active and full of positivity. I enjoy interacting with them, and I am willing to speak up if I feel like to... when my classmates are thinking about the problem very seriously and trying to solve the problem, I feel that I can’t stand by but need to help out.” [K1]
“Especially if your peers are very good at acting, they convince you that the entire process is very authentic and make you more engaged in solving the problems.” [H2]
The friendship-like lecturer-student interaction
The role of the lecturer in the simulation-based learning environment is more like a guide, directing the students forward instead of just giving out answers. Furthermore, they give students ample space for thinking. The lecturer also takes on the role as a “director”, setting up scripts and scenes, observing the actors’ performance, and giving guidance. “The lecturer, as an observer and a questioner, is not an answerer, um, is a helper, a prompter.” [H1] The lecturer-student interaction in the simulation-based learning environment is more “easy-going” and “informal” than that in the traditional classroom.
“The lecturer also participates. The lecturer and we students feel like friends. Unlike in the classroom where one needs to be more respectful when asking the lecturer questions, there is no distinct boundary between the lecturer and students in a simulated learning environment.” [L1]
“The lecturer is more easy-going. The sense of distance and barriers are eliminated.” [Y2]
The lecturer-student relationship in the simulation-based learning environment is based on a more equal footing. There is no hierarchical relationship during knowledge transfer. Instead, the lecturer acts as a consultant. If students are given positive feedback and affirmation in time, they will be more willing to participate.
“That is to say, the lecturer has high expectations for us. Thus, we must definitely treat the course seriously and put in more efforts so as not to disappoint the lecturer.” [W1]