Janet Lefroy, Keele University School of Medicine, Keele, Staffordshire, ST5 5BG, UK. Tel: 00 44 1782 556625; Fax: 00 44 1782 584637; E-mail: email@example.com
Medical Education 2011: 45: 354–361
Objectives This study aimed to determine the impact of giving junior medical students control over the level of emotion expressed by a simulated patient (SP) in a teaching session designed to prepare students to handle emotions when interviewing real patients on placements.
Methods Year 1 medical students at Keele University School of Medicine were allowed to set the degree of emotion to be displayed by the SP in their first ‘emotional interview’. This innovation was evaluated by mixed methods in two consecutive academic years as part of an action research project, along with other developments in a new communications skills curriculum. Questionnaires were completed after the first and second iterations by students, tutors and SPs. Sixteen students also participated in evaluative focus group discussions at the end of Year 1.
Results Most students found the ‘emotion-setting switch’ helpful, both when interviewing the SP and when observing. Student-interviewers were helped by the perception that they had control over the difficulty of the task. Student-observers found it helpful to see the different levels of emotion and to think about how they might empathise with patients. By contrast, some students found the ‘control switch’ unnecessary or even unhelpful. These students felt that challenge was good for them and preferred not to be given the option of reducing it.
Discussion The emotional level control was a useful innovation for most students and may potentially be used in any first encounter with challenging simulation. We suggest that it addresses innate needs for competence and autonomy. The insights gained enable us to suggest ways of building the element of choice into such sessions. The disadvantages of choice highlighted by some students should be surmountable by tutor ‘scaffolding’ of the learning for both student-interviewers and student-observers.
Self-directedness is important for adult learning in a group setting and learners should be encouraged to have choice and control whenever possible.1 Adult learners also value self-esteem and it is important that they do not fail dismally.2 Furthermore, students differ in their self-confidence, risk-taking, self-awareness (metacognition), mastery and performance goals, and varying levels of each of these affect how individuals learn and how much support and challenge each requires.3–5
Teaching in medical schools which supports autonomy has been found to produce a more humanistic approach to the patient, as well as to lower student anxiety, raise self-esteem and enhance learning as evidenced by better test grades.6
Learning should also build on existing knowledge and skills.7,8 Year 1 medical students differ in their pre-existing skills and in terms of how far they are able to extend themselves beyond their existing competence, a characteristic defined by Vygotsky as the ‘width of their zone of proximal development’.9 One of the tutor’s roles is therefore to help the learner progress to the next level of achievement by taking appropriate steps and not to expect the learner to leap an unbridgeable gap.
Learning of social skills is thought to be based on the modelling of others, as per ‘social cognitive learning theory’. Learners are thought to gauge their capabilities not only through their own performance, but also by observing similar others perform, by persuasion from others (‘You can do it!’) and by their physiological indices (heart rate, sweating).10
Student control in simulation
Simulation is used in medical learning to allow students to experiment, to rehearse skills and to obtain immediate feedback in an environment that is safe for both students and patients.11–13 Two features of the ‘simulated (standardised) patient’ (SP) which enable experimentation and re-rehearsing are the ‘pause’ and ‘rewind’ functions. The pause function (which enables the interviewer to pause the interview in order to discuss with observers what is happening and then to proceed with the interview at a pace that suits him- or herself) and the rewind/replay facility (which allows the interviewer or a peer to try different approaches and see what happens) are both examples of contexts in which students are given control to help their learning.13 However, although students have typically been given control over the pace of interviews, there are no studies reporting sessions that give students control over the content of interviews, nor the effects of this extra layer of control on student learning.
For the past 2 years we have given junior medical students control over the level of emotion expressed by an SP in their first ‘emotional interview’. Simulated patients are usually trained to set the emotional temperature as the script or facilitator instructs.13 (An example of a programme for an SP workshop on setting the emotional level and a sample script for an SP are available online in Appendices S1 and S2.) The innovation here was that the student-interviewer had access to a ‘control switch’ to regulate the degree of emotion. This paper describes the impacts of offering such control to students on their learning, behaviour, and peer and self-perception. This is discussed within a theoretical framework which builds on the zone of proximal development and its implications for small-group teaching.
Institution-specific background: the communication skills programme and emotion-setting exercise
The communication skills programme within Keele University’s new medical curriculum was designed by an action research group. One session was designed to prepare Year 1 medical students to handle patients’ emotions by conducting interviews with emotional content about chronic illness with SPs. The design group included a medical student member (author SC), who proposed that the student-interviewer be allowed to set the level of emotion expressed by the SP. SC argued that an emotionally charged interview is a frightening experience for a Year 1 medical student, especially because he or she is performing in front of peers and does not want to fail. It was proposed that giving the student control over the emotional temperature would allow each student to face a challenge appropriate to his or her ability. The underlying hypothesis was that this, in turn, would enable students to learn more effectively, consistent with the theory of the ‘zone of proximal development’.9
In this session, each group of eight or nine students discussed the skills involved in eliciting a patient’s story and how they might handle the challenges they might face on their next placement, in which each student would be required to interview a patient with a chronic condition. Each group then engaged in three simulated interviews in which SPs and student-interviewers rotated. Students interviewed in pairs or alone (their choice), were observed by the rest of the group and were subsequently given feedback. The tutor invited interviewers to choose the level of initial emotion to be expressed by the SP (mild/medium/strong). The SPs had been trained to ‘feel’ and display this level of emotion when the topic of the chronic condition was broached, but also to respond to the student within the interview.
Study population recruitment
The study population comprised the first two cohorts of Year 1 undergraduate medical students in Keele University’s new undergraduate medical curriculum (intakes of September 2007 and September 2008). At the end of their session on handling an emotional interview, all attending students were asked to complete a routine evaluation of their four-session introductory communication skills course and to give their optional informed consent for their responses to be used in research.
A subset of students were recruited to join focus group discussions to evaluate the first year of the new curriculum via an announcement made at a lecture and on the university’s virtual learning environment. Students were asked to indicate (by returning an information slip or by e-mail) their interest in participating in a focus group to include evaluation and research questions or evaluation questions only. Groups were arranged so that as many students as possible could participate within their timetables (it was possible to allocate 26 of 31 volunteers to groups), to ensure as even a gender split as possible, to separate problem-based learning (PBL) groups and to ensure adequate numbers in each group. Five focus groups were held. Two groups included students who wished to participate only in evaluation. The data discussed here come from the other three (research and evaluation) groups. Figure 1 shows how the sample of students related to the year cohorts.
Framework for questioning and analysis of responses
The routine evaluation questionnaire comprised 16 questions on the communication skills course and provided space for written comments (Appendix S3).
Focus group implementation
The focus groups took a modified grounded theory approach.14,15
The moderator (author CB) and assistant were known to the students as the course evaluators and were not their tutors. The focus groups explored a range of issues relating to the new curriculum. As part of this broader evaluation, each group was asked to discuss their experiences of being allowed to set the emotional level of an SP interview.
Focus groups were audio-recorded and the material transcribed with the written consent of the participants. Thematic analysis of transcript data was performed using NVivo 2.0 [QSR International (UK) Limited, Southport, UK]. Tentative interpretations were developed at the time of data collection and the relevant literature was scanned to widen the interpretations. Assumptions were discussed by the action research group in light of the findings; this discussion highlighted exceptions and sought explanations for apparent disagreements.
A total of 121 of the 137 students in the first cycle (88%) and 124 of the 133 students in the second cycle (93%) consented to the inclusion of their routine evaluation data in this study. Both year groups included a majority of female students and were similar in regard to proportions of graduates (Table 1).
Table 1. Gender and graduate status of the study participants
Cohort, Year 1 in:
Female, n (%)
Male, n (%)
Graduates, n (%)
Total study participants, n
Total year group, n
Quotations from questionnaire respondents are annotated with their responses on a Likert scale of Strongly agree–Agree–Disagree–Strongly disagree, with an identification number (e.g. T55 indicates a member of group T5 in 2007; 345 indicates a member of group 34 in 2008), and with the respondent’s gender and graduate status (when positive).
At the end of the first year of the course, 16 students (seven male, nine female) took part in three focus groups. Two of the female students held previous degrees. Focus group members are identified by an initial, their gender and graduate status (when positive).
Students’ evaluations of the ‘emotion-setting switch’
The proportions of students choosing each level of emotion as recorded by group tutors were similar in 2007 and 2008, with around 55% of students requesting that strong emotion be displayed (Fig. 2).
Of the 243 students who responded to the questionnaire item ‘Being able to select the level of emotion in session 4 was very helpful’, 209 (86%) agreed or strongly agreed with the statement (Fig. 3).
Students’ written comments on this item were analysed in terms of expected and contrasting views. The expected view, supported by several student comments, was that giving control to the student enabled the student to feel comfortable, prepared and self-confident and that too much challenge would be negative.
However, a contrasting view also emerged from other student comments, indicating that some students believed challenge to be beneficial and that, as such, it would be better not to be too prepared.
Other themes that emerged in both cycles referred to perceptions that seeing the range of emotions was educational and that the session topic itself was good preparation for placements. These themes are illustrated in Table 2 and developed below.
Table 2. Examples of comments expressing student agreement or disagreement with the statement: ‘Being able to select the level of emotion in session 4 was very helpful’
[Agree] ‘This meant that you were more confident and comfortable – thinking that you had decided on a level you can handle’ (T55, female)
[Agree] ‘…as we weren’t just thrown in the deep end’ (T57, female)
[Strongly agree] ‘Our group selected one of each level – this was very good for comparative purposes’ (345, male, graduate)
[Agree] ‘Although having a varied or unknown level is realistic, at least one strong emotional case is useful’ (336, male)
[Disagree] ‘[The emotion switch] [w]ould only help those who were less confident. I felt most people wanted the challenge of high though’ (T13, female)
[Disagree] ‘…may have been more of a challenge to not know the emotion level’ (F15, male)
Students’ experiences of being in control
The focus groups shed further light on students’ experiences of having control. Contrasting themes emerged. Firstly, having control enabled students to feel comfortable and to adjust the exercise to their learning needs. However, group dynamics also shaped the way control was used and perceived.
Control as a route to comfortable learning for individuals
Students liked being able to control both the pace of the interview and the level of emotion. This student referred to the standard SP facilities of ‘pause’ and ‘rewind’:
‘I think the “pause” and the “rewind” kind of commands were really useful, because you could stop and talk to the group and things like that and that helped a lot rather than carrying on to fail and then talking about how badly you failed. It gave you a chance to correct what you were doing if you were making a mistake.’ (R, male, group 1)
The next student took the discussion on to the additional emotional level control:
‘I’m glad we could choose the levels because I was scared, and I thought if they just came in and they chose themselves that they were going to be really angry or upset, I wouldn’t know how to deal with that, but if we just chose it would be a mild one, you knew how to deal with that better.’ (S, female, group 1)
Here, the ‘control switch’ clearly enabled the student to bring the task into her range of capability, rather than being disabled by the degree of the challenge. Other students in this focus group agreed that the ‘control switch’ made learning more comfortable.
Students also learned from observing the interviews of others. The emotion-setting exercise added value through observation of the handling of different levels of emotion.
Student comments on both the questionnaire and in focus groups about subsequent placement interviews indicated that students transferred this learning to skills used in placement interviews with real patients.
The influence of the group on the interpretation of control
A second major theme identified in the focus group data referred to the idea that challenge is good (and therefore comfort is bad). The fact that this was expressed more often in focus group discussions (in two of the three groups) than in the questionnaire comments may indicate that emotional memories had faded somewhat by the time the focus groups were conducted, but may also reflect the tendency of groups to find consensus, which, in this case, veered towards a group perception of themselves as challenge-seeking. Alternatively, it may be that the students who volunteered for the focus groups were among the more confident or extrovert of the cohort. Nevertheless, what these discussions illustrated was that, in selecting their emotional level, students may have been influenced by the presence of their peers as well as by their individual learning needs.
Focus group discussions revealed that challenge-seeking was regarded by some as a male attribute:
‘All the guys went for the top ones [levels].’ (D, male, group 2)
We do not have data to triangulate with this view on a gender difference, but it is worth noting that the male/female difference in the rating of the helpfulness of the ‘control switch’ was not statistically significant. However, the comment indicates that there may have been an element of bravado in students’ choice of level, as is evident in the same student’s reflection on the risk that the exercise might come to be perceived as more about controlling the SP than about learning to communicate:
‘Instead of focusing on our communication skills, we would be joking around afterwards about how we made an SP cry or did you see the SP, focusing on the SP rather than what we were actually doing – that was the only danger I could see from doing it.’ (D, male, group 2)
Elsewhere in the focus group discussions, students referred to competition within their PBL groups. It appears that competition may also have shaped students’ perceptions of the emotion-setting exercise. This student felt that to choose for comfort was cowardly and that it was good to be challenged by a difficult interview:
‘I don’t think you should be able to pick to be honest. I don’t think you should be allowed to wimp out of it, which I think a lot of people took the easy route and said, “Give me a little bit.” You don’t learn anything from that. You need to go from normal to quite extreme otherwise you are not getting the full benefit of the session.’ (W, female, graduate, group 2)
An element of peer pressure to choose the most difficult level was implied by the comments of more than one student:
‘It is surprising how many people did for go for the higher setting. No-one really chickened out and went for the lower one.’ (A, male, group 3)
It took prompting from the moderator (‘What did you think, F?’) to get another student to admit that she had indeed been daunted by the challenge. This student used the same judgemental term (‘chicken’) to describe herself while defending her need to choose the mild emotional level:
‘I found it quite hard, I didn’t really know how to deal with patients. I chickened out and went for the low one, but I think it is good to introduce it to us. We will be dealing with patients who are upset and angry – any range of emotions.’ (F, female, group 3)
The choosing of the emotional level was therefore interpreted by some students within a normative framework in which a decision to face stronger emotion was more highly valued.
Our study suggests that giving students choice over the level of emotion expressed by an SP in their first emotional interview is helpful for two main reasons. Firstly, student comments demonstrate the intended effect of the ‘control switch’ in line with the constructivist principles of enabling learning in the zone of proximal development.10 Students were able to build their new learning as far out from their existing level of competence as they wished, making use of the teaching at the beginning of the session, as well as the help offered by the group if they paused the interview because they were struggling. Secondly, because the ‘switch’ enabled students to tailor the learning experience to their abilities, some chose to be challenged beyond the level at which we, as tutors, would have set the emotional temperature. This broadened the learning experience for the whole group and equipped them better for the range of experiences they encountered on placements. This fits with social constructivist views such as those of Vygotsky,9 which stress that social group learning is useful. As students model for and observe one another, they not only teach skills, but experience higher self-efficacy for learning.8,9,10 This benefit to observers provides the group with an opportunity for interviewers to legitimately choose a range of levels between them.
Giving learners choice in a group setting is not always straightforward and some disadvantages to the provision of the ‘emotion-setting switch’ emerged. By contrast with the intended effect, choice also emphasises differences between students which can reduce self-esteem and create peer pressure. This indicates the complexity of the processes by which students make decisions about the challenges they choose to face.
Many medical students are competitive.4 This may make it difficult for some to choose a comfortable level of challenge. Both the challenge-seeking and the challenge-averse may choose a level for optimal learning that is inappropriate to their zone of proximal development.
Another explanation (other than peer pressure) for our students’ antipathy to choice is that some students observing an interview in which the interviewer chose a mild emotional level may have wished the emotional temperature to have been higher for their own learning as observers. They may have rationalised this by thinking it would be ‘good’ for their interviewing colleague(s). The benefit of seeing interviews with different emotional levels and how to handle them was certainly perceived as an added bonus of the ‘emotion-setting switch’.
Strengths and weaknesses
The strengths of this study include its mixed-methods approach, which involved the administration of a class-wide questionnaire and the conducting of focus groups that enabled the in-depth exploration of concepts and the further refinement of group members’ thoughts.16 Its weaknesses include the fact that the focus group evaluation was required to be part of the broader curriculum evaluation and may not have achieved saturation of ideas on all themes. Focus groups can overemphasise consensus.17 There was also a delay of 6 months between the teaching session and the focus groups.
Students’ choices are driven by a complex web of peer pressure, challenge seeking and fear of failure and the tutor’s task in such sessions is demanding. Constructivist learning theories state that in order to work within their zone of proximal development, individual learners may need the content of learning to be ‘scaffolded’ by teachers.10,18 Our tutor notes to this purpose are shown in Table 3.
Table 3. Suggestions for the ‘scaffolding’ of simulation in a group setting
The tutor can ‘scaffold’ the learning of both interviewers and observers by:
Orienting participants respectively to the task for the interviewer and the learning opportunities for the observers
Enabling self-assessment of their capabilities, an understanding of the ‘zone of proximal development’ and sensible choice by interviewers
Encouraging a supportive group response to differing educational needs to enable choice and train better medical teachers of the future
Diverting any focus on peripheral aspects of the situation such as the acting prowess of the simulated patient
Autonomy-supportive teaching is to be commended in medical education because of its many positive outcomes for both students and patients. The findings of this study probably apply to medical educators who are interested in giving students choice in any group setting. The next stage in our exploration of emotional level control is to re-evaluate its use with explicit scaffolding by tutors to determine whether the negative impacts of competitiveness and peer pressure can be reduced.
SC conceived the idea of giving students choice in simulated interviews and served as a medical student member of the action research group. CB conducted the focus group interviews and contributed to the analysis and review of the findings. JL led the action research group, which designed and evaluated the innovation, and wrote the initial draft of the paper. All authors contributed to the critical revision of the paper and approved the final manuscript for publication.
the authors thank Professor R K McKinley for advice and encouragement at every stage of this project, Vanessa Hooper for assistance with the focus groups, and Alastair Imrie for training our simulated patients.
Conflicts of interest:
this study was approved by Keele University School of Medicine Ethics Committee.