Emotional regulation strategies (ER) used by trainees to overcome negative emotions

Objective: To identify the use of different emotion regulation strategies by medical trainees, and to determine the frequency and the predominant pattern of emotional response in emotion-triggering situations. Method: The descriptive cross-sectional study was conducted at 2 public and 1 private medical college in Lahore, Pakistan, from March to September 2019, and comprised postgraduate medical trainees of either gender from all clinical disciplines from years 1-4. Data was collected using a questionnaire based on the Gross theory of emotional regulation and the Situational model of emotion. Emotion regulation strategies included situation selection, situation modification, cognitive change, attention deployment, and response modulation. Data was analysed using SPSS 25. Results: Of the 377 trainees approached, 308(81.69%) participated; 206(67%) females and 102(33%) males. The overall mean age was 27.8 ± 2.91 years. The majority of the trainees were from the Obstetrics and Gynaecology department 133(43.2%) and were in the first year of their training 116(37.7%). The most frequent emotion-triggering situation identified was prolonged working hours 292(95%), and the major emotional response was quietness in 5 out of ten situations (50%). The trainees used greater emotion regulation strategies in sad situations 3.49±1.79 (p<0.01). Trainees managed sad emotions by keeping themselves involved in other activities 152(49%); in anger, they blamed others 124(40.3%); in fear, they opted for suppression of emotions 71(22.7%); in disgust, they preferred avoidance 90(29.2%); and in shock, acceptance was a common strategy 21(12.7%). Conclusion: Postgraduate medical trainees struggled to manage emotions and used maladaptive strategies.


Introduction
Emotions are of fundamental importance in the life of every health professional and these emotions affect their social behaviour. 1Health professionals interact with patients and colleagues, and in this phase of learning undergo a complex process of emotional labour. 2 This process of emotional labour is greatest among junior doctors and in trainees dealing with emotionally challenging situations. 3High workloads and responsibilities place these doctors at higher risk of developing mental health problems and burnout. 4otional regulation is a multifaceted process having valance (positive or negative), behavioural and physiological response that is accompanied by specific thoughts and feelings. 5The positive emotions help in decision making, define an appropriate course of action, inform about other behavioural intentions and motivate socially appropriate behaviour and change the situation in which the emotion is expressed in desirable ways. 6rmful emotions are negative emotions, like sadness, shock, fear, disgust and anger, that are aroused in difficult situations which need to be managed using the emotion regulation process.Harmful emotions are associated with mal-adaption in cognition and behaviour. 7e Gross process theory of emotions describes that individuals can control emotions through the emotional regulation process by using some strategies, and these emotions unfold over some time. 8Strategies are categorised into both antecedents-focussed and response-focussed.Antecedent-focussed strategies occur during the genesis of emotion, and response-modulation strategies occur after the experience of emotion.Antecedent-focussed strategies are situation selection (SS), situation modification (SM), attention deployment (AD), and cognitive change (CC) that occur in sequence.
Most studies have focussed on one or more strategies, like re-appraisal and expressive suppression, to manage emotions. 3,5,7However, in negative emotional situations, the person can use multiple strategies for the same situation rather than a single strategy to control emotions.Some strategies are used on encountering the situation, others during and a few after the situation.The situational model 7 based on the Gross Theory of emotion is used to answer the research question as to how a trainee uses multiple strategies in five negative emotions that change over sometime (Figure 1).This theoretical model helps in determining the relative success of strategies employed in clinical settings.
Considering the lack of literature on emotion regulation and its management in a clinical setting, the current study was planned to identify the use of different emotion regulation strategies in dealing with negative emotions, and to determine the predominant pattern of emotional response in emotion-triggering situations.

Subjects and Methods
The descriptive cross-sectional study was conducted at 2 public and 1 private medical college in Lahore, Pakistan, from March to September 2019.Approval for the study was obtained from the ethics review boards of the University of Lahore and the Sharif Medical and Dental College, Lahore.Using convenience sampling technique, the study included postgraduate medical trainees of either gender from all clinical disciplines and from years 1 -4 of their training.Medical students and house officers were excluded.The sample size was calculated using WHO sample size calculator with 95% confidence interval (CI), anticipated population proportion 0.60 (60%) 7 , and margin of error of 5%. 9ta was collected using questionnaires designed following the steps given in the Association for Medical Education in Europe (AMEE) guide. 10rough literature search, themes were identified to define the construct and the measures related to the emotional regulation construct.To measure construct, 10 items were developed for the first questionnaire (Annexure 1) and 21 items for the second questionnaire (Annexure 2).
The first questionnaire had 2 components; emotiontriggering situations, and emotional response to such situations.
The second questionnaire was about emotion regulation strategies in negative situations.
The second step involved discussions among the coauthors to ensure that the conceptualisation of the construct made theoretical sense and the appropriateness of its language for the population of interest.
The third step was data synthesis, followed by updating of the items.The next step involved content validations, for which the questionnaires were emailed to 12 experts, including subject specialists, psychologists and medical educationalists.The content validity forms were sent to these experts via email and were asked to accept, reject or suggest modification for each item.The relevance of items was based on the score of each item from 1-4, ranging from not relevant to very relevant.The items were further refined on the basis of their feedback.
Content validity index (CVI) of individual items (I-CVI) and of the scale (S-CVI) was calculated with two methods, S-CVI/Average and S-CVI/ universal agreement (UA), using the rating of items based on relevance by the content experts.
The next step 6 involved cognitive probing for trainees' understanding.Five trainees from the Obstetrics and Gynaecology (OB-GYN) department were selected for concurrent verbal cognitive probing.Criteria used for concurrent probing included correct item interpretation, comprehensible explanation, answer choice compatibility with interpretation, and overall item cognition by the five trainees.
The final step involved pilot testing and final modification to adjust items.The two questionnaires were distributed randomly to 65 postgraduate trainees (PGTs) selected from different clinical specialties to determine the reliability of the instruments.The reliability was calculated using Cronbach alpha and split-half reliability.The first questionnaire had two components whereas the second questionnaire had one component.Cronbach alpha was calculated for the 1st component of the questionnaire and a split-half reliability test was used for the 2nd component of the first questionnaire.For the second questionnaire, only split-half reliability was calculated for multiple response analysis.
The content validity index obtained for the first questionnaire was S-CVI/Ave 0.9 and S-CVI/UA 0.7.Internal consistency measured by Cronbach alpha was 0.77 (Annexure 3).
The second questionnaire had S-CVI/Ave of 0.9 and S-CVI/UA of 0.80, respectively, and internal consistency using the split-half reliability was 0.8 (Annexure 4).
The first component of the first questionnaire comprised 10 situations with a range of options scored on a Likert scale, ranging from 0 = never to 5 = always.These items inquired about the situations at the workplace which generated negative emotions.In the second component, the emotional response of the PGTs in these situations was inquired.
The second questionnaire had 18 items about strategies to regulate negative emotions.These items were categorised into 'before', 'during', and 'after' the negative emotional situation (Figure 2), including fear, disgust, sad, angry, and shock, against which these strategies were used.The strategies were operationally defined as: SS meaning to attend or not to attend the situation; SM meaning modifying the situation after attending; AD meaning redirecting attention towards or away from the situation; and CC meaning using some coping strategies to manage the situation, like acceptance, planning, reappraisal, positive refocussing, and putting into perspective.
Data was analysed using SPSS 25.Demographic data was presented using descriptive statistics for categorical variables, like age, gender, year of study, and specialty, as frequencies and percentages.Choice of strategies was compared with reference to gender and year of training.
Repeated measure analysis of variance (ANOVA) was used to determine the significant negative emotional situation using strategies in 'before' 'during' and 'after' phases.P<0.05 was considered significant.

S.No
Clinical situation The trainees used greater emotion regulation strategies in sad situations 3.49±1.79(p<0.01)(Table 3).

Discussion
Dealing with emotions and learning to manage emotions is an important component of professional behaviour.
Workplace and clinical environments are far from ideal places and trainee doctors should transform seamlessly from students to professionals in order to face stressful situations as patiently as possible.
The emotionally challenging situations could be due to personal factors (personality trait, career development, opportunities, mental health problems etc.), interpersonal relationship factors (colleagues, staff nurses, and patients and their attendants), or organisational and responsibility factors (prolonged working hours).The major factor identified as emotiontriggering in the current study was prolonged working hours by 292(95%) subjects, followed by the rude behaviour of patients or their attendants towards health professionals 289(94%).The results are consistent with earlier findings. 2,11,12cidences of rude behaviour of patients and their relatives are becoming increasingly common, and affect the interaction between patients and doctors.Understanding the perspective of patients and effective communication strategy, in simulation-based learning appears to be an effective tool in the teaching of the trainees to handle such conflicts. 13Simulation-based training for conflict management was not routinely practised in the hospitals that took part in the current study.
The emotional response of individuals varies in different situations and reflects the emotional sensitivity to that situation.Emotional sensitivity (initial response) to the situation is not only influenced by the nature of stimuli, but also by personal characteristic (personality trait) which determines the subsequent coping response of an individual that is called the emotion regulation process. 14he current study also determined the emotional responses generated in different situations.A total of 10 situations were identified that could trigger negative emotions.In five out of 10 such situations, the major emotional response (50%) was quietness, followed by a discussion with others and aggressiveness, when there was rude behaviour of patients.The results are comparable to earlier studies. 13,15The reason might be that most of the trainees were from first year, and, lower down in the hierarchy, they felt powerless, had limited knowledge and experience, and failed to struggle with challenging situations that influenced their emotional and behavioural response.
In addition to identifying the frequency of negative emotions, another important element is how trainees react to negative emotions.The current study found that 292(95%) respondents recognised prolonged working hours as the major factor, while the most common emotional reaction was aggressiveness 107(34%), followed by loss of interest in work 70(22%), and both were emotion-focussed maladaptive responses.
The results are consistent with findings from junior doctors in Australia that work-related stress is identified as a major reason for psychological distress. 16e current study also determined the emotional regulation strategies in 5 negative emotions.SM strategy by 152(49%) subjects was used when dealing with sad emotions, while in a disgusting situation, SS strategy was preferred by 90(29.2%).This was consistent with the finding of a study in the United Kingdom. 17appraisal is more effective in down-regulating negative emotional experience, and in the current study, 95(30.8%)subjects managed anger using this strategy.However expressive suppression was used to manage fear by 54(17.5%).Expressive suppression is a less effective strategy compared to reappraisal as it does not downregulate negative emotional experience, and is positively linked to psychopathology.
The fourth and the last aspect of the current study was to see how the trainees controlled their emotions.While in the middle of a situation, most trainee opted for AD (rumination) and CC (planning).More females (60.8%) and year-1 trainees (21.2%) used these two strategies.A metaanalysis also found that to deal with negative emotions, females were more likely to use rumination and need emotional support from others. 18Rumination is a maladaptive strategy and a strong predictor for mood, anxiety disorder and depression, and is associated with long working hours and work-related burnout among healthcare professionals. 7,19e current study found that after the situation, suppression of emotions, and crying (seeking social support) was used as a strategy in disgust and sad emotional state, particularly among the females.A study found that the strategies after the situation were physical distraction and crying, and that suppression during a situation and expression after the experience was the preferred strategy.The emotional dysregulation identified in the current study not only hinders their learning, achievement, goal-oriented behaviour, and adaption to the emotion regulation process, but also affects a compassionate, caring attitude towards the patients. 15,18e current study has limitations, as it designed the instrument to cover 5 major negative emotions, while leaving out others, including jealousy, lust, panic/grief, rage and contempt.
The strength of the study is that it included trainees from all years of training and from all clinical disciplines.Longitudinal studies with larger samples on trainees from different countries should be conducted to compare the inter-cultural variation in emotion regulation for negative emotions and response to them.

Conclusion
The trainees struggled to manage emotions and used maladaptive strategies.Sadness was the most common discrete emotion, followed by anger, fear, disgust and shock.Lack of cognitive coping strategies and the use of maladaptive strategies in high demanding situations identified the need for emotional development programmes.

Disclaimer:
The text is based on a Master in Health Professions Education (MHPE) project.
Annexure 2: Questionnaire 2: Emotion regulation strategies questionnaire.Instructions: I will ask you some questions about your emotional life, in particular, how you control (that is, regulate and manage) your negative emotions.Negative emotional reactions include Sad, Angry, Fear, Disgust and Shock.These reactions are described below.Sad: Thoughts of loss or failure, for example; when I lose a patient, in spite of my best efforts to save his/her life Anger: Thoughts of having been harmed, having been treated unfairly, for example; rude behaviour of patients or their attendants towards staff Fear: Thoughts of having done something that goes against your own morals, for example; wrong dispensing of medicines to patients by staff or something went wrong by you while managing a patient Disgust: A feeling of revulsion or strong disapproval aroused by something unpleasant, for example; the humiliation of junior colleagues by senior colleagues in front of patients Shock: A sudden upsetting or surprising event or experience, for example; uncivilized and rude behaviour of doctors towards patients Different emotional regulation strategies are used for the control of these emotions some strategies are used before, others are used during and some are used after encountering the difficult clinical situations.For example: You encounter a situation of breaking the bad news to one of your patients who is being admitted in hospital in and waiting for reports for a few days.You feel sad when you heard the reports are not good.I will cry sometime when I feel these emotions.

17.
I take a sleep or some medicine like a pill to relax when I feel these emotions.

18.
I go for a walk, exercise, movie, or have shopping , watch TV or read, to think less about these emotions

Table 1 :
Frequency and pattern of emotional responses in emotion-triggering situations.
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Table - 3
Types and patterns of emotional regulation strategies in negative emotions.: Mean difference in the use of emotion regulation strategies among five negative emotions.

Continued from previous page... In reaction to this news before breaking news to the patient:
Your strategy would be either you decided to break bad news yourself and take responsibility but your other strategy during this situation would be, you ask your colleague to break the bad news to the patient.Your third strategy could be to bring your colleagues with you and try to break some component of news or you become involved in other activities like writing patient notes to detach yourself from the development of the emotional reaction.During this situation of breaking news, you think about how you can best explain to the patient without expressing your sadness or you feel that you can learn something from disclosing the news to the patient.After you have gone through the situation and explained to the patient, you go home and feel sad and in order to reduce this emotional reaction, your strategy could be to take a pill to relax, you go for walk or continuously focus on the situation and criticize yourself or you share your feelings with others.