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.
This is a preview of subscription content, access via your institution.
Buy single article
Instant access to the full article PDF.
Price excludes VAT (USA)
Tax calculation will be finalised during checkout.
It is also possible that a reciprocal relationship exists between these processes.
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.
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.
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).
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.
Names from quotations have been replaced with the individual’s role during the simulation to protect anonymity.
Ahearn, G. S., Hadjiliadis, D., Govert, J. A., & Tapson, V. F. (2002). Massive pulmonary embolism during pregnancy successfully treated with recombinant plasminogen activator: A case report and review of treatment options. Archives of Internal Medicine, 162, 1221–1227.
Artino, A. R. (2013). When I say…emotion in medical education. Medical Education, 47, 1062–1063.
Artino, A. R., Holmboe, E. S., & Durning, S. J. (2012). Control-value theory: Using achievement emotions to improve understanding of motivation, learning, and performance in medical education: Amee guide no. 64. Medical Teacher, 34, 148–160.
Artino, A. R., La Rochelle, J. S., & Durning, S. J. (2010). Second year medical students’ motivational beliefs, emotions, and achievement. Medical Education, 44, 1203–1212.
Azevedo, R. (2014). Issues in dealing with sequential and temporal characteristics of self- and socially-regulated learning. Metacognition and Learning, 9, 217.
Azevedo, R., Harley, J., Trevors, G., Duffy, M., Feyzi-Behnagh, R., Bouchet, F., et al. (2013). Using trace data to examine the complex roles of cognitive, metacognitive, and emotional self-regulatory processes during learning with multi-agents systems. In R. Azevedo & V. Aleven (Eds.), International handbook of metacognition and learning technologies (pp. 427–449). New York, NY: Springer.
Azevedo, R., Mudrick, N., & Taub, M. (in press a). The coupling between metacognition and emotions during STEM learning with advanced learning technologies: A theoretical framework. In Y. J. Dori, Z. Mevarech, & D. Baker (Eds.), Cognition, metacognition, and culture in STEM education. Amsterdam: Springer.
Azevedo, R., Taub, M., & Mudrick, N. (in press b). Using research methods to investigate emotions in computer-based learning environments. In P. Schutz & M. Zembylas (Eds.), Methodological advances in research on emotion and education. Amsterdam: Springer.
Baurjeily, B. (2010). Pulmonary embolism in pregnancy. The Lancet, 375, 500–512.
Ben-Eliyahu, A., & Linnenbrink-Garcia, L. (2013). Extending self-regulated learning to include self-regulated emotion strategies. Motivation and Emotion, 37(3), 558–573.
Bion, J. F., & Heffner, J. E. (2004). Challenges in the care of the acutely ill. The Lancet, 363(9413), 970–977.
Boekaerts, M. (2011). Emotions, emotion regulation, and self-regulation of learning. In B. Zimmerman & D. Schunk (Eds.), Handbook of self-regulation of learning and performance (pp. 408–425). New York, NY: Routledge.
Bond, W. F., Deitrick, L. M., Arnold, D. C., Kostenbader, M., Barr, G. C., Kimmel, S. R., et al. (2004). Using simulation to instruct emergency medicine residents in cognitive forcing strategies. Academic Medicine, 79, 438–446.
Brydges, R., & Butler, D. (2012). A reflective analysis of medical education research on self-regulation in learning and practice. Medical Education, 46, 71–79.
Butler, D., & Brydges, R. (2013). Learning in the health professions: What does self-regulation have to do with it? Medical Education, 47, 1053–1057.
Butler, E. A., & Gross, J. J. (2009). Emotion and emotion regulation: Integrating individual and social levels of analysis. Emotion Review, 1, 86–87.
Cannon-Bowers, J. A., & Salas, E. (2001). Reflctions on shared cognition. Journal of Organizational Behavior, 22, 195–202.
Cheng, A., Donoghue, A., Eilfoyle, E., & Eppich, W. (2012). Simulation-based crisis resource management training for pediatric critical care medicine: A review for instructors. Critical Care Medicine, 13, 197–203.
Chew, B. H., Zain, A. M., & Hassan, F. (2013). Emotional intelligence and academic performance in first and final year medical students: A cross-sectional study. BMC Medical Education, 13, 1–10.
Creswell, J. W. (2006). Qualitative inquiry and research design: Choosing among five approaches (2nd ed.). Thousand Oaks, CA: Sage.
Croskerry, P. (2003). Cognitive forcing strategies in clinical decision making. Annals of Emergency Medicine, 41, 110–120.
Croskerry, P., Abbass, A. A., & Wu, A. W. (2008). How doctors feel: Affective issues in patients’ safety. The Lancet, 372(9645), 1205–1206. doi:10.1016/S0140-6736(08)61500-7.
de Vries, E. N., Ramrattan, M. A., Smorenburg, S. M., Gouma, D. J., & Boermeester, M. A. (2008). The incidence and nature of in-hospital adverse events: A systematic review. Quality and Safety in Health Care, 17(3), 216–223.
Durning, S. J., Cleary, T. J., Sandars, J., Hemmer, P., Kokotailo, P., & Artino, A. R. (2011). Viewing “strugglers” through a different lens: How self-regulated learning perspective can help medical educators with assessment and remediation. Academic Medicine, 86, 488–495.
Ekman, P. (1992). An argument for basic emotions. Cognition and Emotion, 6, 169.
Ekman, P. (2003). Darwin, deception, and facial expression. Annals of the New York Academy of Science, 1000, 205–221.
Ekman, P., & Friesen, W. V. (1978). Facial action coding system: A technique for the measurement of facial movement. Palo Alto, CA: Consulting Psychologists Press.
Gaba, D. M. (2010). Crisis resource management and teamwork training in anaesthesia. British Journal of Anaesthesia, 105, 3–6.
Gaba, D. M., Fish, K. J., & Howard, S. K. (1994). Crisis management in anesthesiology. New York, NY: Churchill Livingstone.
Greenberg, S. B., Tokarczyk, A., & Small, S. (2011). Critical care simulation. Disease-a-month, 57(11), 715–722. doi:10.1016/j.disamonth.2011.08.010.
Gross, J. J. (2014). Emotion regulation: Conceptual and empirical foundations. In J. J. Gross (Ed.), Handbook of emotion regulation (2nd ed., pp. 3–20). New York, NY: Guilford.
Gross, J. J., & Barrett, L. F. (2011). Emotion generation and emotion regulation: One or two depends on your point of view. Emotion Review, 3, 8–16.
Hadwin, A. F., & Oshige, M. (2011). Self-regulation, co-regulation, and socially-shared regulation: Exploring perspectives of social in self-regulated learning theory. Teachers College Record, 113(2), 240–264.
Isen, A. M. (2000). Positive affect and decision making. In M. Lewis & J. Haviland-Jones (Eds.), Handbook of emotion (2nd ed., pp. 417–435). New York, NY: Guilford.
Kanaga, K., & Kossler, M. E. (2011). How to form a team: Five keys to high performance. Greensboro, NC: Center for Creative Leadership.
Kim, J., Neilipovitz, D., Cardinal, P., & Chiu, M. (2009). A comparison of global rating scale and checklist scores in the validation of an evaluation tool to assess performance in the resuscitation of critically ill patients during simulated emergencies. Simulation Healthcare, 4, 6–16.
Kim, J., Neilipovitz, D., Cardinal, P., Chiu, M., & Clinch, J. (2006). A pilot study using high-fidelity simulation to formally evaluate performance in the resuscitation of critically ill patients: The University of Ottawa Critical Care Medicine, high-fidelity simulation, and crisis resource management i study. Critical Care Medicine, 34(8), 2167–2174.
Kohn, K. T., Corrigan, J. M., & Donaldson, M. S. (1999). To err is human: Building a safer health system. Washington, DC: National Academies Press.
Koole, S. L. (2009). The psychology of emotion regulation: An integrative review. Cognition and Emotion, 29, 4–41.
Lajoie, S. P., & Lu, J. (2009). Supporting collaboration with technology: Does shared cognition lead to co-regulation in medicine? Metacognition and Learning, 7, 45–62.
Lazarus, R. S. (1991). Emotion and adaptation. New York: Oxford University Press.
Leonard, M., Graham, S., & Bonacum, D. (2004). The human factor: The critical importance of effective teamwork and communication in providing safe care. Quality and Safety in Health Care, 13, 85–90.
Lingard, L., Regehr, G., Orser, B., Reznick, R., Baker, G. R., Doran, D., et al. (2008). Evaluation of a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures in communication. Archives of Surgery, 143, 12–17.
Manser, T., & Foster, S. (2011). Effective handover communication: An overview of research and improvement efforts. Best Practice & Research: Clinical Anaesthesiology, 25(2), 181–191.
Matsumoto, D., & Hwang, H. S. (2011). Evidence for training the ability to read microexpressions of emotion. Motivation and Emotion, 35(2), 181–191.
McConnell, M. M., & Eva, K. W. (2012). The role of emotion in the learning and transfer of clinical skills and knowledge. Academic Medicine, 87, 1316–1322.
McGaghie, W. C., Issenberg, S. B., Petrusa, E. R., & Scalese, R. J. (2010). A critical review of simulation-based medical education research: 2003–2009. Medical Education, 44, 50–63.
Mega, C., Ronconi, L., & De Beni, R. (2014). What makes a good student? How emotions, self-regulated learning and motivation contribute to academic achievement. Journal of Educational Psychology, 106(1), 121–131.
Meinhardt, J., & Pekrun, R. (2003). Attentional resource allocation to emotional events: An ERP study. Cognition and Emotion, 17, 477–500.
Molenaar, I., & Järvelä, S. (2014). Sequential and temporal characteristics of self and socially regulated learning. Metacognition and Learning, 9, 75.
Pedersen, R. (2009). Empirical research on empathy in medicine: A critical review. Patient Education and Counseling, 76(3), 307–322. doi:10.1016/j.pec.2009.06.012.
Pekrun, R. (1992). The impact of emotions on learning and achievement: Towards a theory of cognitive/motivational mediators. Applied Psychology: An International Review, 41, 359–376.
Pekrun, R. (2006). The control-value theory of achievement emotions: Assumptions, corollaries, and implications for educational research and practice. Educational Psychology Review, 18, 315–341.
Pekrun, R. (2014). Control-value theory of achievement emotions. In R. Pekrun & L. Linnenbrink-Garcia (Eds.), International handbook of emotions in education (pp. 120–141). New York: Routledge.
Pekrun, R., Frenzel, A. C., Goetz, T., & Perry, R. P. (2007). The control-value theory of achievement emotions: An integrative approach to emotions in education. In P. A. Schutz & R. Pekrun (Eds.), Emotion in education (pp. 13–36). San Diego, CA: Academic Press.
Pekrun, R., Goetz, T., Frenzel, A. C., Barchfeld, P., & Perry, R. P. (2011). Measuring emotions in students’ learning and performance: The achievement emotions questionnaire (AEQ). Contemporary Educational Psychology, 36, 36–48.
Pekrun, R., Goetz, T., & Titz, W. (2002). Academic emotions in students’ self-regulated learning and achievement: A program of qualitative and quantitative research. Educational Psychologist, 37, 91–105.
Pintrich, P. R. (2000). The role of goal orientation in self-regulated learning. In M. Boekaerts, P. Pintrich, & M. Zeidner (Eds.), Handbook of self-regulation (pp. 451–502). San Diego, CA: Academic Press.
Pintrich, P. (2004). A conceptual framework for assessing motivation and self-regulated learning in college students. Educational Psychology Review, 16, 385–407.
Rothschild, J. M., Landrigan, C. P., Cronin, J. W., Kaushal, R., Lockley, S. W., Burdick, E., et al. (2005). The critical care safety study: The incidence and nature of adverse events and serious medical errors in intensive care. Critical Care Medicine, 33, 1694–1700.
Salas, E., & Cannon-Bowers, J. A. (2001). The science of training: A decade of progress. Annual Review of Psychology, 52, 471–499.
Salas, E., Cooke, N. J., & Rosen, M. A. (2008a). On teams, teamwork, and team performance: Discoveries and developments. Human Factors: The Journal of the Human Factors and Ergonomics Society, 50, 540–547.
Salas, E., DiazGranados, D., Weaver, S. J., & King, H. (2008b). Does team training work? Principles for healthcare. Academic Emergency Medicine, 15, 1002–1009.
Salas, E., Rosen, M. A., & King, H. (2007). Managing teams managing crises: Principles of teamwork to improve patient safety in the emergency room and beyond. Theoretical Issues in Ergonomics Science, 8, 381–394.
Salas, E., Sims, D. E., & Burke, C. S. (2005). Is there ‘‘big five’’ in teamwork? Small Group Research, 36, 555–599.
Sandars, J. (2013). When I say… self-regulated learning. Medical Education, 47, 1162–1163.
Sandars, J., & Cleary, J. T. (2011). Self-regulation theory: Applications to medical education. Medical Teacher, 33, 875–886.
Schraw, G. (1998). Processing and recall differences among seductive details. Journal of Educational Psychology, 90, 3–12.
Schraw, G. (2010). Measuring self-regulation in computer-based learning environments. Educational Psychologist, 45(4), 258–266.
Schraw, G., & Dennison, R. S. (1994). Assessing metacognitive awareness. Contemporary Educational Psychology, 19(4), 460–475.
Torbicki, A., Perrier, A., Konstantinides, S., Agnelli, G., Galiè, N., Pruszczyk, P., et al. (2008). Guidelines on the diagnosis and management of acute pulmonary embolism. European Heart Journal, 29, 2276–2315.
Turrentine, M. A., Braems, G., & Ramirez, M. M. (1995). Use of thrombolytics for the treatment of thromboembolic disease during pregnancy. Obstetrical & Gynecological Survey, 50, 534–541.
Volet, S., & Summers, M. (2013). Interpersonal regulation in collaborative learning activities: Reflections on emerging research methodologies. In S. Volet & M. Vauras (Eds.), Interpersonal regulation of learning and motivation: Methodological advances. London, England: Routledge.
Volet, S., Vauras, M., & Salonen, P. (2009). Self- and social regulation in learning contexts: An integrative perspective. Educational Psychologist, 44(4), 215–226.
Webster's english dictionary: Concise edition for school, home and office. (2005). Toronto: Strathearn Books Limited.
White, C. (2007). Smoothing out transitions: How pedagogy influences medical students’ achievement of self-regulated learning goals. Advances in Health Sciences Education, 12, 279–297.
Wildman, J. L., Shuffler, M., Lazzara, E. H., Fiore, S., Burke, C. S., Salas, E., et al. (2012). Trust development in swift starting action teams: A multilevel framework. Group and Organization Management, 37, 138–170.
Winne, P. H., & Azevedo, R. (2013). Metacognition. In K. Sawyer (Ed.), Cambridge handbook of the learning sciences (2nd ed.). Cambridge: Cambridge University Press.
Winne, P., & Hadwin, A. (1998). Studying as self-regulated learning. In D. Hacker, J. Dunlosky, & A. Graesser (Eds.), Metacognition in educational theory and practice (pp. 227–304). Mahwah, NJ: Erlbaum.
Winne, P. H., & Hadwin, A. F. (2008). The weave of motivation and self-regulated learning. In D. H. Schunk & B. J. Zimmerman (Eds.), Motivation and self-regulated learning: Theory, research and application (pp. 297–313). New York, NY: Taylor & Francis Group.
Winne, P. H., & Perry, N. E. (2000). Measuring self-regulated learning. In M. Boekaerts, P. Pintrich, & M. Zeidner (Eds.), Handbook of self-regulation (pp. 531–566). Orlando, FL: Academic Press.
Wood, K. E. (2002). Major pulmonary embolism: Review of pathophysiologic approach to the golden hour of hemodynamically significant pulmonary embolism. Chest, 121, 877–905.
Zeelenberg, M. (1998). Emotional reactions to the outcomes of decisions: The role of counterfactual thought in the experience of regret and disappointment. Organizational Behavior and Human Decision Processes, 75, 117–141.
Zeidner, M. (1998). Test anxiety: The state of the art. New York, NY: Plenum Press.
Zimmerman, B. (2001). Theories of self-regulated learning and academic achievement: An overview and analysis. In B. J. Zimmerman & D. H. Schunk (Eds.), Self-regulated learning and academic achievement: Theoretical perspectives (2nd ed., pp. 1–33). Mahwah, NJ: Erlbaum.
Zimmerman, B. J., & Schunk, D. H. (2008). Motivation: An essential dimension of self-regulated learning. In B. J. Zimmerman & D. H. Schunk (Eds.), Motivation and self-regulated learning: Theory, research, and application (p. 130). New York, NY: Erlbaum.
Zimmerman, B., & Schunk, D. H. (Eds.). (2011). Handbook of self-regulation of learning and performance. New York, NY: Routledge.
Ziv, A., Ben-David, S., & Ziv, M. (2005). Simulation based medical education: An opportunity to learn from errors. Medical Teacher, 27, 193–199.
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.
See Table 4
About this article
Cite this article
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