Predictable chaos: a review of the effects of emotions on attention, memory and decision making

Novice students navigating the clinical environment in an early medical clerkship

CONTEXT

The black box that is student learning in clinical environments is an ongoing research project. Our previous research showed that despite the time that students are given to learn with, about and from patients, some lack confidence for those encounters and see few patients. The study reported here investigated individual and environmental factors affecting medical students' self-directed learning time in hospital.

METHODS

We studied second year students in the four-year postgraduate Melbourne Medical School programme as they undertook the first of their four 9-week hospital placements in medical wards. Each week approximately 10 hours of structured teaching is offered; the remaining time is spent in self-directed learning. Over six weeks, we observed 31 medical students and interviewed 17 of them. The interviews were subjected to content analysis procedures and the observation notes added contextual information to what was said in interviews. We considered the findings through the Experience-based Learning framework.

RESULTS

We found four main themes in the data: finding and contacting patients challenges all students and overwhelms some; the educational design of the placement is a flawed navigational device providing inadequate clarity and security; the physical and social terrain of a large tertiary hospital is replete with obstacles making it easy for some students to stumble and retreat; finally, any positive connection with peers, staff and patients is empowering.

CONCLUSIONS

This study throws light on to the uncertain path of the novice clinical learner illuminating both the intractable aspects of hospital environments and opportunities for pedagogical and affective supports that can compensate. The processes and conditions for self-directed learning time need attention in order to provide for a safe, efficient or successful clerkship experience for all students. Particular effort is needed to sensitively identify those individuals who struggle and suffer on the journey, and provide appropriate support.

Medical students' reflections on emotions concerning breaking bad news

OBJECTIVES

To gain a deeper understanding of fourth year medical students' reflections on emotions in the context of breaking bad news (BBN).

METHODS

During the years 2010-2012, students reflected on their emotions concerning BBN in a learning assignment at the end of the communications skills course. The students were asked to write a description of how they felt about a BBN case. The reflections were analysed using qualitative content analysis.

RESULTS

351 students agreed to participate in the study. We recognized ten categories in students' reflections namely empathy, insecurity, anxiety, sadness, ambivalence, guilt, hope, frustration, gratefulness and emotional detachment. Most students expressed empathy, but there was a clear tension between feeling empathy and retaining professional distance by emotional detachment.

CONCLUSIONS

Students experience strong and perplexing emotions during their studies, especially in challenging situations. A deeper understanding of students' emotions is valuable for supporting students' professional development and coping in their work in the future.

PRACTICE IMPLICATIONS

Medical students need opportunities to reflect on emotional experiences during their education to find strategies for coping with them. Emotions should be actively discussed in studies where the issues of BBN are addressed. Teachers need education in attending emotional issues constructively.

A Test and Extension of Lane and Terry's (2000) Conceptual Model of Mood-Performance Relationships Using a Large Internet Sample

The present study tested and extended Lane and Terry (2000) conceptual model of mood-performance relationships using a large dataset from an online experiment. Methodological and theoretical advances included testing a more balanced model of pleasant and unpleasant emotions, and evaluating relationships among emotion regulation traits, states and beliefs, psychological skills use, perceptions of performance, mental preparation, and effort exerted during competition. Participants (N = 73,588) completed measures of trait emotion regulation, emotion regulation beliefs, regulation efficacy, use of psychological skills, and rated their anger, anxiety, dejection, excitement, energy, and happiness before completing a competitive concentration task. Post-competition, participants completed measures of effort exerted, beliefs about the quality of mental preparation, and subjective performance. Results showed that dejection associated with worse performance with the no-dejection group performing 3.2% better. Dejection associated with higher anxiety and anger scores and lower energy, excitement, and happiness scores. The proposed moderating effect of dejection was supported for the anxiety-performance relationship but not the anger-performance relationship. In the no-dejection group, participants who reported moderate or high anxiety outperformed those reporting low anxiety by about 1.6%. Overall, results showed partial support for Lane and Terry's model. In terms of extending the model, results showed dejection associated with greater use of suppression, less frequent use of re-appraisal and psychological skills, lower emotion regulation beliefs, and lower emotion regulation efficacy. Further, dejection associated with greater effort during performance, beliefs that pre-competition emotions did not assist goal achievement, and low subjective performance. Future research is required to investigate the role of intense emotions in emotion regulation and performance.

The simulated clinical environment: Cognitive and emotional impact among undergraduates

CONTEXT

Simulated clinical immersion (SCI) is used in undergraduate healthcare programs to expose the learner to real-life situations in authentic simulated clinical environments. For novices, the environment in which the simulation occurs can be distracting and stressful, hence potentially compromising learning.

OBJECTIVES

This study aims to determine whether SCI (with environment) imposes greater extraneous cognitive load and stress on undergraduate pharmacy students than simulated patients (SP) (without environment). It also aims to explore how features of the simulated environment influence students' perception of learning.

METHODS

In this mixed-methods study, 143 undergraduate pharmacy students experienced both SCI and SP in a crossover design. After the simulations, participants rated their cognitive load and emotions. Thirty-five students met in focus groups to explore their perception of learning in simulation.

RESULTS

Intrinsic and extraneous cognitive load and stress scores in SCI were significantly but modestly higher compared to SP. Qualitative findings reveal that the physical environment in SCI generated more stress and affected students? focus. In SP, students concentrated on clinical reasoning. SCI stimulated a focus on data collection but impeded in-depth problem solving processes.

CONCLUSION

The physical environment in simulation influences what and how students learn. SCI was reported as more cognitively demanding than SP. Our findings emphasize the need for the development of adapted instructional design guidelines in simulation for novices.

Old practices, new windows: reflections on a communications skills innovation

Most of the great innovations in communication skills education, from Balint's concept of the 'doctor as drug' to the Calgary Cambridge conceptualisation of the consultation, were founded in general practice. It can be argued however, that there has been a hiatus in the development of new approaches to analysing the consultation since the mid-1990s. It is most welcome therefore that in this issue of the journal two papers are presented that describe and evaluate a novel approach to consultation analysis entitled 'the windows method'. Building on the more structured approaches that preceded it, the windows method offers some genuine innovations in terms of its emphasis on emotional knowledge and the manner in which it addresses many of the potential deficiencies in feedback practice associated with older methods. The new approach is very much in step with current thinking about emotional development and the establishment of appropriate environments for feedback. The windows method has the potential to breathe fresh life into old and well-established communication skills education practices.

Twelve tips for applying the science of learning to health professions education

Findings from the science of learning have clear implications for those responsible for teaching and curricular design. However, this data has been historically siloed from educators in practice, including those in health professions education. In this article, we aim to bring practical tips from the science of learning to health professions educators. We have chosen to organize the tips into six themes, highlighting strategies for 1) improving the processing of information, 2) promoting effortful learning for greater retention of knowledge over time, 3) applying learned information to new and varied contexts, 4) promoting the development of expertise, 5) harnessing the power of emotion for learning, and 6) teaching and learning in social contexts. We conclude with the importance of attending to metacognition in our learners and ourselves. Health professions education can be strengthened by incorporating these evidence-based techniques.

The Impact of Emotion on Learners' Application of Basic Science Principles to Novel Problems

PURPOSE

Training to become a physician is an emotionally laden experience. Research in cognitive psychology indicates that emotions can influence learning and performance, but the materials used in such research (e.g., word lists) rarely reflect the complexity of material presented in medical school. The present study examined whether emotions influence learning of basic science principles.

METHOD

Fifty-five undergraduate psychology students were randomly assigned to write about positive, negative, or neutral life events for nine minutes. Participants were then taught three physiological concepts, each in the context of a single organ system. Testing consisted of 13 clinical cases, 7 presented with the same concept/organ system pairing used during training ("near transfer") and 6 with novel pairings ("far transfer"). Testing was repeated after one week with 13 additional cases.

RESULTS

Forty-nine students provided complete data. Higher test scores were found when the concept/organ system pairing was held constant (near transfer = 51% correct vs. far = 33%; P < .001). Emotion condition influenced participants' overall performance, with individuals in the neutral condition (50.1%) performing better than those in the positive (38.2%, P < .05) and negative (37.7%, P < .001) emotion conditions.

CONCLUSIONS

These data suggest that regardless of whether the emotion is positive or negative, mild affective states can impair learning of basic science concepts by novices. Demands on working memory and subsequent cognitive load provide a potential explanation. Future work will examine the extent to which these findings generalize to medical trainees.

Thrive or overload? The effect of task complexity on novices' simulation-based learning

CONTEXT

Fidelity is widely viewed as an important element of simulation instructional design based on its purported relationship with transfer of learning. However, higher levels of fidelity may increase task complexity to a point at which novices' cognitive resources become overloaded.

OBJECTIVES

In this experiment, we investigate the effects of variations in task complexity on novices' cognitive load and learning during simulation-based procedural skills training.

METHODS

Thirty-eight medical students were randomly assigned to simulation training on a simple or complex lumbar puncture (LP) task. Participants completed four practice trials on this task (skill acquisition). After 10 days of rest, all participants completed one additional trial on their assigned task (retention) and one trial on a 'very complex' simulation designed to be similar to the complex task (transfer). We assessed LP performance and cognitive load on each trial using multiple measures.

RESULTS

In both groups, LP performance improved significantly during skill acquisition (p ≤ 0.047, f = 0.29-0.96) and was maintained at retention. The simple task group demonstrated superior performance compared with the complex task group throughout these phases (p ≤ 0.002, d = 1.13-2.31). Cognitive load declined significantly in the simple task group (p < 0.009, f = 0.48-0.76), but not in the complex task group during skill acquisition, and remained lower at retention (p ≤ 0.024, d = 0.78-1.39). Between retention and transfer, LP performance declined and cognitive load increased in the simple task group, whereas both remained stable in the complex task group. At transfer, no group differences were observed in LP performance and cognitive load, except that the simple task group made significantly fewer breaches of sterility (p = 0.023, d = 0.80).

CONCLUSIONS

Reduced task complexity was associated with superior LP performance and lower cognitive load during skill acquisition and retention, but mixed results on transfer to a more complex task. These results indicate that task complexity is an important factor that may mediate (via cognitive overload) the relationship between instructional design elements (e.g. fidelity) and simulation-based learning outcomes.

Ward Rounds With or Without an Attending Physician: How Interns Learn Most Successfully

OBJECTIVE

To explore pediatric interns' perspectives on the educational value of general pediatric ward rounds, in particular their rounding experiences with and without an attending physician.

METHODS

Qualitative study using individual interviews of pediatric interns (2013-2014) rotating on 2 general pediatric inpatient services at different institutions with different rounding team structures. In accordance with grounded theory methodology, data were analyzed using the constant comparative method. Codes were built using an iterative approach and organized into themes.

RESULTS

Twenty pediatric interns participated in 25 interviews. Data analysis yielded 4 themes: what is being learned; learning environment on rounds; learning and work; and ways of learning. Senior residents generally taught practical aspects of patient care and attending physicians taught broader concepts with references to the medical literature. Rounds without an attending physician were perceived as less formal and promoted collaborative discussions with senior residents. Interns were more uncomfortable during rounds with an attending physician but appreciated how that facilitated their learning. Although patient care tasks provided opportunities for experiential learning, interns frequently perceived them to impede learning during rounds. Intern learning during ward rounds occurred via self-directed learning, interactive learning, and through caring for patients. Brief, clinically relevant teaching pearls and questioning clinical reasoning in a respectful manner were helpful.

CONCLUSIONS

Interns learn different content and learn in different ways depending on the presence or absence of an attending physician at rounds. There might be educational value from rounding with teams that include and do not include an attending physician.

Ethical reasoning through simulation: a phenomenological analysis of student experience

Background

Medical students transitioning into professional practice feel underprepared to deal with the emotional complexities of real-life ethical situations. Simulation-based learning (SBL) may provide a safe environment for students to probe the boundaries of ethical encounters. Published studies of ethics simulation have not generated sufficiently deep accounts of student experience to inform pedagogy. The aim of this study was to understand students' lived experiences as they engaged with the emotional challenges of managing clinical ethical dilemmas within a SBL environment.

Methods

This qualitative study was underpinned by an interpretivist epistemology. Eight senior medical students participated in an interprofessional ward-based SBL activity incorporating a series of ethically challenging encounters. Each student wore digital video glasses to capture point-of-view (PoV) film footage. Students were interviewed immediately after the simulation and the PoV footage played back to them. Interviews were transcribed verbatim. An interpretative phenomenological approach, using an established template analysis approach, was used to iteratively analyse the data.

Results

Four main themes emerged from the analysis: (1) 'Authentic on all levels?', (2)'Letting the emotions flow', (3) 'Ethical alarm bells' and (4) 'Voices of children and ghosts'. Students recognised many explicit ethical dilemmas during the SBL activity but had difficulty navigating more subtle ethical and professional boundaries. In emotionally complex situations, instances of moral compromise were observed (such as telling an untruth). Some participants felt unable to raise concerns or challenge unethical behaviour within the scenarios due to prior negative undergraduate experiences.

Conclusions

This study provided deep insights into medical students' immersive and embodied experiences of ethical reasoning during an authentic SBL activity. By layering on the human dimensions of ethical decision-making, students can understand their personal responses to emotion, complexity and interprofessional working. This could assist them in framing and observing appropriate ethical and professional boundaries and help smooth the transition into clinical practice.

Content and discontent: a qualitative exploration of obstacles to elearning engagement in medical students

BACKGROUND

Elearning is ubiquitous in healthcare professions education. Its equivalence to 'traditional' educational delivery methods is well established. There is a research imperative to clarify when and how to use elearning most effectively to mitigate the potential of it becoming merely a 'disruptive technology.' Research has begun to broadly identify challenges encountered by elearning users. In this study, we explore in depth the perceived obstacles to elearning engagement amongst medical students. Sensitising concepts of achievement emotions and the cognitive demands of multi-tasking highlight why students' deeply emotional responses to elearning may be so important in their learning.

METHODS

This study used focus groups as a data collection tool. A purposeful sample of 31 participated. Iterative data gathering and analysis phases employed a constant comparative approach to generate themes firmly grounded in participant experience.

RESULTS

Key themes that emerged from the data included a sense of injustice, passivity and a feeling of being 'lost at sea'. The actual content of the elearning resource provided important context.

CONCLUSIONS

The identified themes have strong emotional foundations. These responses, interpreted through the lens of achievement emotions, have not previously been described. Appreciation of their importance is of benefit to educators involved in curriculum development or delivery.

Preparing Our Future Helping Professionals to Become Critical Thinkers: A Tutorial

Critical thinking is increasingly recognized as an essential knowledge and skill for the helping professions. Yet, our pedagogical literature has provided infrequent guidance on how instructors can help students to understand what “critical thinking” means or how it might contribute to their professional lives. Therefore, the purpose of this tutorial is to provide guidelines on how instructors might teach future practitioners to become critical thinkers. The main topics address an instructional definition of critical thinking, the basic knowledge and skills that comprise critical thinking, a broad view of instructional approaches, and a summary of developmental milestones of adult critical thinkers. Specific teaching strategies from instructors who have hands-on experience with guiding their students to become critical thinkers are included.

Effect of Extrinsic and Intrinsic Stressors on Clinical Skills Performance in Third-Year Medical Students

BACKGROUND

Both enhancements and impairments of clinical performance due to acute stress have been reported, often as a function of the intensity of an individual's response. According to the broader stress literature, peripheral or extrinsic stressors (ES) and task-contingent or intrinsic stressors (IS) can be distinguished within a stressful situation. The objective of this study was to assess the impact of IS and ES on clinical performance.

METHOD

A prospective randomized crossover study was undertaken with third-year medical students conducting two medical experiences with simulated patients. The effects of severity of the disease (IS) and the patient's aggressiveness (ES) were studied. A total of 109 students were assigned to four groups according to the presence of ES and IS. Subjective stress and anxiety responses were assessed before and after each experience. The students' clinical skills, diagnostic accuracy and argumentation were assessed as clinical performance measures. Sex and student-perceived cognitive difficulty of the task were considered as adjustment variables.

RESULTS

Both types of stressors improved clinical performance. IS improved diagnostic accuracy (regression parameter β = 9.7, p = 0.004) and differential argumentation (β = 5.9, p = 0.02), whereas ES improved clinical examination (β = 12.3, p < 0.001) and communication skills (β = 15.4, p < 0.001). The student-perceived cognitive difficulty of the task was a strong deleterious factor on both stress and performance.

CONCLUSION

In simulated consultation, extrinsic and intrinsic stressors both have a positive but different effect on clinical performance.