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Team regulation in a simulated medical emergency: An in-depth analysis of cognitive, metacognitive, and affective processes

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Abstract

This study examined the nature of cognitive, metacognitive, and affective processes among a medical team experiencing difficulty managing a challenging simulated medical emergency case by conducting in-depth analysis of process data. Medical residents participated in a simulation exercise designed to help trainees to develop medical expertise, effective leadership, and team management skills. Purposive sampling was used to select one team for case study based on overall performance. Video and audio data were collected from the simulation and debriefing session and a follow-up interview was conducted with the team leader. Performance measures were also collected from expert raters (i.e., experienced staff physicians). Video data were reviewed and coded for cognitive, metacognitive, and emotional events exhibited by team members during the simulation. Interview and debriefing transcripts were coded for themes related to these regulatory processes. Results from quantitative and qualitative analyses revealed that the team exhibited lower-order cognitive and metacognitive process (e.g., summarizing, providing information) more often than higher-order processes (e.g., evaluation, reasoning). Furthermore, team members expressed negative emotions (e.g., anxiety) more often than positive emotions (e.g., enjoyment). Chi square analyses of the team leader revealed that negative emotions were significantly more frequently preceded by lower-order processes compared to higher-order processes. Qualitative thematic analyses provided further corroboration of these findings. The findings suggest that medical trainees (particularly teams experiencing difficulty managing a challenging case) may require further scaffolding in their use of regulatory processes within medical emergencies. The results from this study are discussed in terms of implications for theories of self-regulation, methodological advances, and instructional design for medical education.

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Notes

  1. It is also possible that a reciprocal relationship exists between these processes.

  2. Negative activating emotions (e.g., anxiety) appear to have a more variable relationship with achievement (Pekrun et al. 2011; Pekrun 1992).

  3. This study is part of a larger research program on crisis resource management simulation training. For the purposes of this case study, we selected one team and one case from a sample of 3 teams (N = 17 residents) that each participated in 3 case simulations (hyperkalemia, pulmonary embolism, upper gastrointestinal bleed) during a half-day training session.

  4. Medical expert ratings for the leader were lower (M = 1.42) compared to the average across all leaders for this case (M = 2.05, SD = 0.59). CRM ratings for the leader were lower (M = 3.13) compared to average across all leaders for this case (M = 4.76, SD = 1.53). The team also reported lower prior CRM skills (M = 2.00, SD = 0.71) compared to the average across teams (M = 2.27, SD = 0.70) and lower post-training CRM skills (M = 2.26) compared to the average across all teams (M = 3.20, SD = 0.86), which indicates less effective CRM skills.

  5. Percentages represent the frequency and amount of time (s) that a particular category occurred (e.g., duration of monitoring) compared to the total number of events or duration of events that occurred for the process (e.g., total duration of metacognitive events).

  6. Planning was considered lower-order given that the follow-up analyses of its quality revealed that in almost half of the cases, it was not executed effectively.

  7. Names from quotations have been replaced with the individual’s role during the simulation to protect anonymity.

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Acknowledgments

This research was supported by funding from a McGill University Collaborative Research Grant and the Canada Research Chairs program awarded to the second author. We would like to acknowledge the Arnold and Blema Steinberg Medical Simulation Centre for supporting this research. We would also like to thank Inderpal Dhillon for his assistance with data entry and coding. 

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Authors and Affiliations

  1. Department of Educational and Counselling Psychology, Faculty of Education, McGill University, 3700 McTavish Street, Montreal, QC, H3A 1Y2, Canada

    Melissa C. Duffy, Sophia E. Griscom & Victoria Stead

  2. Department of Psychology, North Carolina State University, Raleigh, USA

    Roger Azevedo

  3. Division of General Internal Medicine, McGill University, Montreal, Canada

    Ning-Zi Sun, Jeffrey Wiseman & Thomas Maniatis

  4. Arnold and Blema Steinberg Medical Simulation Centre, McGill University, Montreal, Canada

    Linda Crelinsten & Kevin Lachapelle

  5. Division of Cardiac Surgery, McGill University, Montreal, Canada

    Kevin Lachapelle

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  1. Melissa C. Duffy
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Correspondence to Melissa C. Duffy.

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Duffy, M.C., Azevedo, R., Sun, NZ. et al. Team regulation in a simulated medical emergency: An in-depth analysis of cognitive, metacognitive, and affective processes. Instr Sci 43, 401–426 (2015). https://doi.org/10.1007/s11251-014-9333-6

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