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Analyzing Multimodal Data to Understand Medical Trainees' Regulation Strategies and Physiological Responses in High- Fidelity Medical Simulation Scenarios

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Title: Analyzing Multimodal Data to Understand Medical Trainees' Regulation Strategies and Physiological Responses in High- Fidelity Medical Simulation Scenarios
Language: English
Authors: Matthew Moreno (ORCID 0000-0002-7155-8103), Lucia Patino Melo, Keerat Grewal (ORCID 0000-0002-0130-6015), Negar Matin, Sayed Azher (ORCID 0000-0001-8840-1981), Jason M. Harley (ORCID 0000-0002-2061-9519)
Source: Metacognition and Learning. 2024 19(3):1161-1213.
Availability: Springer. Available from: Springer Nature. One New York Plaza, Suite 4600, New York, NY 10004. Tel: 800-777-4643; Tel: 212-460-1500; Fax: 212-460-1700; e-mail: customerservice@springernature.com; Web site: https://link.springer.com/
Peer Reviewed: Y
Page Count: 53
Publication Date: 2024
Document Type: Journal Articles
Reports - Research
Education Level: Higher Education
Postsecondary Education
Descriptors: Data Analysis, Medical Students, Trainees, Self Control, Responses, Simulation, Fidelity, Skill Development, Teamwork, Psychophysiology, Simulated Environment
DOI: 10.1007/s11409-024-09403-z
ISSN: 1556-1623
1556-1631
Abstract: Medical simulations allow trainees to work within teams to develop their self-regulated learning (SRL) and socially-shared regulated learning (SSRL) skills (Bransen et al., 2022). Both skillsets help to better prepare medical trainees for the multifaceted challenges inherent in clinical practice. SRL skills are imperative in empowering learners to optimize their performance and become autonomous guiders of their own learning (Jarvela & Hadwin, 2013), while SSRL skills are needed to ensure that teams can work collectively to regulate their behaviors and to regulate their own learning to make decisions (Hadwin & Oshige, 2011). Questions remain about not only how medical trainees' behaviors, regulation strategies, and physiological responses vary while they participate in a high-fidelity medical simulation, but how additional data channels to measure human response can provide indicators of teams' regulation strategies. Using a mixed-methods convergence design incorporating multimodal data (Azevedo & Gaševic, 2019), including behavioral, SRL and SSRL codes, and electrodermal activity, researchers studied twenty-nine (N = 29) 1st to 3rd year medical residents as they engaged in high-fidelity simulation scenarios. Results suggest that the mean-level of psychophysiological activation increase as simulations progress, in conjunction with an increase in team-regulated learning strategies to manage the effective provision of patient care from initial contact through to the delivery of critical procedures. These results provide valuable insights into the advancement of a team regulation-based framework within a high-fidelity medical simulation environment, leveraging multimodal data to reach an understanding of medical trainees' adoption of team-based approaches to team-regulation during simulation scenarios.
Abstractor: As Provided
Entry Date: 2024
Accession Number: EJ1445647
Database: ERIC
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  Value: <anid>AN0180499035;[3d0h]01dec.24;2024Oct29.06:09;v2.2.500</anid> <title id="AN0180499035-1">Analyzing multimodal data to understand medical trainees' regulation strategies and physiological responses in high- fidelity medical simulation scenarios </title> <p>Medical simulations allow trainees to work within teams to develop their self-regulated learning (SRL) and socially-shared regulated learning (SSRL) skills (Bransen et al., 2022). Both skillsets help to better prepare medical trainees for the multifaceted challenges inherent in clinical practice. SRL skills are imperative in empowering learners to optimize their performance and become autonomous guiders of their own learning (Jarvela & Hadwin, 2013), while SSRL skills are needed to ensure that teams can work collectively to regulate their behaviors and to regulate their own learning to make decisions (Hadwin & Oshige, 2011). Questions remain about not only how medical trainees' behaviors, regulation strategies, and physiological responses vary while they participate in a high-fidelity medical simulation, but how additional data channels to measure human response can provide indicators of teams' regulation strategies. Using a mixed-methods convergence design incorporating multimodal data (Azevedo & Gašević, 2019), including behavioral, SRL and SSRL codes, and electrodermal activity, researchers studied twenty-nine (N = 29) 1st to 3rd year medical residents as they engaged in high-fidelity simulation scenarios. Results suggest that the mean-level of psychophysiological activation increase as simulations progress, in conjunction with an increase in team-regulated learning strategies to manage the effective provision of patient care from initial contact through to the delivery of critical procedures. These results provide valuable insights into the advancement of a team regulation-based framework within a high-fidelity medical simulation environment, leveraging multimodal data to reach an understanding of medical trainees' adoption of team-based approaches to team-regulation during simulation scenarios.</p> <p>Keywords: Crisis resource management; Group regulation; Medical simulation; Medical education; Electrodermal activity; Mixed methods</p> <p>Copyright comment Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.</p> <hd id="AN0180499035-2">Introduction</hd> <p>Crisis Resource Management (CRM) is a core set of skills and behaviors that can be applied to a variety of crisis environments, including medicine, and are an integral component of medical trainees' curriculum. These skills include leadership, communication, problem-solving, resource utilization, and situational awareness (Burke et al., [<reflink idref="bib21" id="ref1">21</reflink>]; Carne et al., [<reflink idref="bib22" id="ref2">22</reflink>]; Fernandez Castelao et al., [<reflink idref="bib31" id="ref3">31</reflink>]; Marsch et al., [<reflink idref="bib72" id="ref4">72</reflink>]). The application of CRM within medical simulations (Carne et al., [<reflink idref="bib22" id="ref5">22</reflink>]; Reznek et al., [<reflink idref="bib79" id="ref6">79</reflink>]) allows medical trainees to work as part of a team, made up of leaders and team members, to practice scenarios to develop these skills (Lai et al., [<reflink idref="bib64" id="ref7">64</reflink>]) in a constructive, formative environment (Brydges et al., [<reflink idref="bib20" id="ref8">20</reflink>]; Teis et al., [<reflink idref="bib83" id="ref9">83</reflink>]). These opportunities to practice team-based medical activities provide a structured environment to help develop medical skills as well as experience the type of team-based work environment that mirrors clinical practice. It is through these scenarios that medical trainees are offered the opportunity to develop the regulatory skills that will form the basis of their ability to effectively manage and be part of medical teams.</p> <hd id="AN0180499035-3">Individual and team regulation in learning</hd> <p>Self-regulated learning (SRL) is defined as the process wherein individuals manage their learning through preparatory planning, performance, and appraisal of their work (Jansen et al., [<reflink idref="bib50" id="ref10">50</reflink>]; Zimmerman, [<reflink idref="bib92" id="ref11">92</reflink>]). Effective SRL requires setting goals, metacognitively monitoring performance, and engaging in self-reflection to maintain motivation for ongoing learning. Different models of regulation including the COPES model by Winnie and Hadwin ([<reflink idref="bib89" id="ref12">89</reflink>]), Boekaerts and Cascallar' Dual Processing Model ([<reflink idref="bib12" id="ref13">12</reflink>]), Harley and colleague's Emotion Regulation in Achievement Situations (ERAS; [<reflink idref="bib43" id="ref14">43</reflink>]), and others, have described how learners process and regulate themselves throughout various phases that results from appraisals and strategies they employ. Regulation can occur within an individual at the behavioral (Kazemitabar et al., [<reflink idref="bib58" id="ref15">58</reflink>]), affective (Ben-Eliyahu & Linnenbrink-Garcia, [<reflink idref="bib9" id="ref16">9</reflink>]; Li et al., [<reflink idref="bib69" id="ref17">69</reflink>]) cognitive (Harley et al., [<reflink idref="bib42" id="ref18">42</reflink>], [<reflink idref="bib43" id="ref19">43</reflink>]; Lajoie et al., [<reflink idref="bib67" id="ref20">67</reflink>]), and motivational levels (Efklides, [<reflink idref="bib29" id="ref21">29</reflink>]; Järvenoja et al., [<reflink idref="bib57" id="ref22">57</reflink>]) and plays a critical role in a learners' ability to further their learning​. A challenge faced by medical trainees, both in medical simulations and real-world clinical rotations, is the ability to regulate their learning because of the shifting dynamics of medical practice and its high-stress nature (Bransen et al., [<reflink idref="bib18" id="ref23">18</reflink>]), which puts a burden and premium on learners being able to incorporate SRL strategies into their continual learning. Beyond the need to manage and regulate individuals, team members need to be able to come together and work as a team (Hadwin et al., [<reflink idref="bib39" id="ref24">39</reflink>], [<reflink idref="bib41" id="ref25">41</reflink>]) to achieve common goals and effective performance.</p> <p>Socially-shared regulated learning (SSRL) pertains to the collaborative regulation of learning among learners (Hadwin & Oshige, [<reflink idref="bib40" id="ref26">40</reflink>]; Jarvela & Hadwin, [<reflink idref="bib51" id="ref27">51</reflink>]), requiring the negotiation of personal interests, shared goal-setting, and management of the team as they work. Effective SSRL is highly contextual (Järvenoja et al., [<reflink idref="bib56" id="ref28">56</reflink>]) and requires negotiation between members to determine their shared goals in a task, as well as how those goals will be met, as metrics for how they will be accountable in accomplishing said goals (Hadwin et al., [<reflink idref="bib39" id="ref29">39</reflink>], [<reflink idref="bib41" id="ref30">41</reflink>]). The collaborative nature of SSRL requires members to be actively engaged in the negotiation of their shared mental models for accomplishing their tasks in order to be successful in making effective use of resources and time in their work (Järvelä et al., [<reflink idref="bib52" id="ref31">52</reflink>]). SSRL requires the individual learner to come into their collaborative work environment with an understanding of how their own skills, abilities, and emotions influence the work that they do in this team-based environment. (Isohätälä et al., [<reflink idref="bib47" id="ref32">47</reflink>]; Isohätälä et al., [<reflink idref="bib49" id="ref33">49</reflink>]). Through SSRL, medical learners need to balance their own needs within the context of effective team management and their collective learning. The skills needed to master SSRL are developed from SRL but require focused training and intentional development in order to hone these skills in medical practice. Managing SRL skills are essential for individual learning in medical training, while SSRL skills are critical as medical professionals spend the majority of their time working as part of teams, and are needed to help model the life-long learner ethos of medical education (Johnson et al., [<reflink idref="bib53" id="ref34">53</reflink>]).</p> <hd id="AN0180499035-4">Regulation in medical training</hd> <p>Studies have suggested that, if medical trainees do not have a foundation applying self-regulation, then team-regulation becomes difficult in medical situations resulting in decreased patient care outcomes (Bransen et al., [<reflink idref="bib16" id="ref35">16</reflink>], [<reflink idref="bib17" id="ref36">17</reflink>]). The cognitive challenges experienced by medical trainees, along with their demanding schedules and the stress-inducing nature of clinical training, highlight the potential negative consequences when individuals lack personal autonomy in their learning. Specifically, such circumstances can adversely impact team effectiveness when confronted with the added pressures of team dynamics. Research on regulation amongst medical trainees has suggested that offering self-regulation training to medical residents can enhance their self-awareness regarding their actions within team-regulation contexts (Bransen et al., [<reflink idref="bib16" id="ref37">16</reflink>], [<reflink idref="bib17" id="ref38">17</reflink>]), in addition to improving performance through a greater sharing of information and a more successful execution of learning objectives/patient care (Innocenti et al., [<reflink idref="bib46" id="ref39">46</reflink>]).</p> <p>Further studies in surgical education have confirmed that providing a framework for residents to become more aware of their regulation abilities allows them to become better managers of their own performance and members of teams during surgical practice (Johnson et al., [<reflink idref="bib53" id="ref40">53</reflink>]; Turan & Konan, [<reflink idref="bib85" id="ref41">85</reflink>]). In addition, studies examining general practice/family medicine (Sagasser et al., [<reflink idref="bib80" id="ref42">80</reflink>]) and pre-clinical training (Versteeg et al., [<reflink idref="bib88" id="ref43">88</reflink>]) have further suggested that a focus on SRL cultivates increased awareness among medical students and residents regarding their cognitive processes. This allows for their learning to be more explicit and consequently facilitates tracking meaningful progress. As has been noted by researchers (Bransen & Govaerts, [<reflink idref="bib15" id="ref44">15</reflink>]; Gandomkar et al., [<reflink idref="bib34" id="ref45">34</reflink>]), SRL is often studied using resident self-reports and by engaging in binary, pass-fail, formative assessments that negate the nuance of learner development and performance.</p> <p>Medical simulation-training scenarios allow researchers to capture the nuances of team-based medical training while also providing medical trainees with the opportunity to improve their technical skills and acquire the knowledge needed to deliver optimized patient care. In addition to the clinical skills needed to be a board-certified practitioner, simulations also provide trainees with an environment for interpersonal skills development, such as teamwork, communication, leadership and SRL skills (Brydges et al., [<reflink idref="bib19" id="ref46">19</reflink>], [<reflink idref="bib20" id="ref47">20</reflink>]). These simulations also allow for the development of team regulation-behaviors and strategies (Panadero et al., [<reflink idref="bib76" id="ref48">76</reflink>]), which are essential because trainees are required to work in teams. Despite knowing the value of team-level regulation, many trainees are unsure how this regulation occurs (Bransen et al., [<reflink idref="bib16" id="ref49">16</reflink>], [<reflink idref="bib17" id="ref50">17</reflink>]; Bransen et al., [<reflink idref="bib16" id="ref51">16</reflink>], [<reflink idref="bib17" id="ref52">17</reflink>]) or how to recognize the explicit indicators of this regulation. Focusing on self-reflection and feedback, which can be incorporated into the learner's debriefing from facilitators, is one way to enhance these skills that are critical for trainees' lifelong learning in the medical professions.</p> <p>There is a growing need in the literature to describe the observable behaviors shown by individual medical trainees, in addition to the regulation strategies that are practiced between learners. The existing literature is mainly focused on describing SRL and SSRL skills within clinical residency training (Artino et al., [<reflink idref="bib4" id="ref53">4</reflink>]; Gandomkar et al., [<reflink idref="bib33" id="ref54">33</reflink>]), and thus there has been less literature examining SRL and SSRL in the context of simulation residency training, especially within the scope of CRM training. Focusing on the pre-clinical development of SRL and SSRL skills in the context of medical simulations allows medical trainees to use that environment to experiment, home, and train the use of these regulatory skills to develop their facility to effectively employ them once high-stakes, clinical rotations begin. Furthermore, there is a continual need to expand how researchers are monitoring SRL and SSRL, and an increasing awareness of the need to incorporate reliable measures of human feedback and physiological response.</p> <hd id="AN0180499035-5">Multimodal analysis and human response</hd> <p>The study of human feedback and response has often relied on the study of electrodermal activity (EDA). EDA refers to the variations in the electrical conductance of the skin as a type of 'sweating' that is produced as an autonomic response by the eccrine glands. Researchers have indicated that EDA is a reliable measure of sympathetic arousal without interference from parasympathetic activity. EDA signals have a tonic (skin conductance level; SCL) and phasic (skin conductance response; SCR) component to them (Boucsein, [<reflink idref="bib14" id="ref55">14</reflink>]). SCL accounts for slow changes in EDA, while SCR corresponds to rapid changes, with are generally seen as being tied to specific stimuli in your environment. The research team chose to examine skin conductance responses (SCRs) as part of the physiological analysis. SCR is produced through short bursts within the sympathetic nervous activity which result in increases to the frequency and/or amplitude of the EDA to indicate changes in sympathetic arousal. SCRs can take anywhere from 1–5 s to be recorded (Boucsein, [<reflink idref="bib14" id="ref56">14</reflink>]) following stimulation due to the latency inherent in EDA from stimulus onset to when the SCR is recorded. Due to the SCR analysis accounting for changes in frequency and/or amplitude of phasic response, the establishment of a baseline if not necessary in this analysis due to automated protocols of SCR detection and extraction (Boucsein, [<reflink idref="bib14" id="ref57">14</reflink>]). EDA has been widely linked to autonomic emotional processes, making it a valuable index for assessing the arousal that comes from an emotionally engaged activity (Dindar et al., [<reflink idref="bib25" id="ref58">25</reflink>]; Harley et al., [<reflink idref="bib42" id="ref59">42</reflink>], [<reflink idref="bib43" id="ref60">43</reflink>]; Moreno & Woodruff, [<reflink idref="bib73" id="ref61">73</reflink>]; Schuurmans et al., [<reflink idref="bib81" id="ref62">81</reflink>]; van Dooren et al., [<reflink idref="bib87" id="ref63">87</reflink>]; Zhai & Barreto, [<reflink idref="bib91" id="ref64">91</reflink>]). These signals can be measured within teams, enabling researchers to examine the interpersonal physiological dynamics among team members. These responses provide insights into the level of autonomic nervous system (ANS) activation, involving both the excitatory sympathetic (SNS) and inhibitory parasympathetic (PNS) branches. Psychophysiological signal measurement has been widely used in research to explore the connection between individuals' emotional and cognitive states and their physiological responses.</p> <p>The application of EDA as a tool to identify and manage activation and stress has been explored in the literature. Research into the identification of increased EDA within surgeons has led to the suggestion that, by identifying this activation, better reflection and mitigation strategies can be used to help minimize the negative effects of stress (Arora et al., [<reflink idref="bib3" id="ref65">3</reflink>]; Bond et al., [<reflink idref="bib13" id="ref66">13</reflink>]; Dias & Scalabrini-Neto, [<reflink idref="bib23" id="ref67">23</reflink>]; Doulougeri et al., [<reflink idref="bib26" id="ref68">26</reflink>]; Grewal & Heather, [<reflink idref="bib36" id="ref69">36</reflink>]; Kharatzadeh et al., [<reflink idref="bib61" id="ref70">61</reflink>]; Maher et al., [<reflink idref="bib71" id="ref71">71</reflink>]). Research into the application of EDA within medical simulations (Bond et al., [<reflink idref="bib13" id="ref72">13</reflink>]; Dias & Scalabrini-Neto, [<reflink idref="bib23" id="ref73">23</reflink>]) has suggested that making medical trainees more aware of their emotions can help them to better understand how their bodies respond during simulated training to be able to better manage those responses in future activities.</p> <p>The introduction of multiple data streams to understand SRL and SSRL necessitate the use of multimodal, mixed-method research techniques (Azevedo & Gašević, [<reflink idref="bib7" id="ref74">7</reflink>]) as a set of tools to bring together human observation, learner feedback and regulation skills into a space where each of these modalities can provide added value to create a more complete understanding of regulatory processes. Work from Järvelä ([<reflink idref="bib54" id="ref75">54</reflink>]) has supported the use of multimodal data as a means of overcoming the deficiencies of using singular channels to understand collaboration. Hence, pairing self-reported data with psychophysiological feedback, namely EDA (Dindar et al., [<reflink idref="bib25" id="ref76">25</reflink>]) allows us to investigate the link between SRL processes and psychophysiological activation. Previous studies examining the connections between psychophysiological responses and observed SRL and SSRL have suggested that as the needs of collaborative tasks increase on team members, they display increased physiological activation, coinciding with an increase in social regulatory factors (Törmänen et al., [<reflink idref="bib86" id="ref77">86</reflink>]). Research from Törmänen ([<reflink idref="bib86" id="ref78">86</reflink>]) also suggested connections between affective and physiological activation during these events. In addition, research from Järvelä and colleagues ([<reflink idref="bib55" id="ref79">55</reflink>]) have explored the prediction of team regulation through physiological activation, suggesting that varying levels of high, medium, and low activation map onto collaborative patterns in young, elementary learners. What studies in medical education have focused on is identifying psychophysiological activation as a byproduct of overall performance, without examining what SRL and SSRL effects might be seen within the medical trainees, especially in team-based learning environments. Likewise, simulated learning environments are a unique setting to incorporate multimodal data from learning sciences. What is absent in the literature is an analysis of how medical trainees' physiological activation may be related to the SRL and SSRL strategies that they employ during medical simulations.</p> <hd id="AN0180499035-6">Research objectives</hd> <p>We aimed to study the different SRL and SSRL strategies and psychophysiological responses of teams during different segments of medical simulations. Specifically, we identified and coded segments of each simulation as 'Beginning, 'Escalation' and 'Peak' moments, and then examined how observable behaviors, regulation strategies, and psychophysiological responses varied across these critical points in the simulation. By analyzing smaller sub-units of a simulation, we aimed to better understand the types of strategies and physiological activation signals that can assist in making medical trainees more aware of their responses over the course of simulated patient scenario. We used the following questions to guide this study:</p> <p></p> <ulist> <item> <bold> RQ1. </bold> How do medical trainees' regulation strategies (SRL, SSRL) differ as they complete the 'Beginning', 'Escalation', and 'Peak' of a medical simulation?</item> <p></p> <item> <bold> RQ2. </bold> How do medical trainees' psychophysiological responses differ as they complete the 'Beginning', 'Escalation', and 'Peak' of a medical simulation?</item> </ulist> <hd id="AN0180499035-7">Methods</hd> <p>Prior to beginning this study, our research protocol was approved by the university's IRB. All participants consented to their inclusion in the study and were informed of their rights to freely consent and to withdraw that consent at any time.</p> <hd id="AN0180499035-8">Research methodology</hd> <p>This was a cross-sectional observational study with multimodal data collected from medical residents while they took part in Crisis Resource Management (CRM) simulated training sessions. The medical learning objectives varied across simulated scenarios, but the overall goals were the ability to demonstrate a systematic approach to the assessment of a medical problem, the capacity to promptly recognize the clinical challenges, and the capability to provide appropriate treatment. This design allowed the research team to collect observed data, including behaviors and the SRL and SSRL strategies that were exhibited during medical simulations (Apramian et al., [<reflink idref="bib2" id="ref80">2</reflink>]; Young et al., [<reflink idref="bib90" id="ref81">90</reflink>]).</p> <p>Content analysis was used (Berger-Estilita et al., [<reflink idref="bib11" id="ref82">11</reflink>]) to code for leaders' SRL, SSRL, and behaviors. These codes emerged as a result of both inductive and deductive coding (Albert et al., [<reflink idref="bib1" id="ref83">1</reflink>]) to create a more authentic examination of how the leader performed during simulation. At the same time, testing these codes on our data helped refine and enhance the research team's understanding of how SRL and SSRL relate to leadership and CRM skills. Psychophysiological data collected from participants during these sessions added depth to the analysis and helped confirm the direction of reasoning.</p> <hd id="AN0180499035-9">Participants</hd> <p>A total of twenty-nine (<emph>N</emph> = 29<emph>)</emph> 1st through 3rd year residents participated. They all had comparable levels of training and clinical experience to other residents in their program. Simulations were recorded between March 2022 and August 2022 at the university's simulation training center. Medical residents belonged to different residency programs (fourteen in Internal Medicine, nine in Emergency Medicine, three in Critical Care, and three in Anesthesiology) at a North American university. Participants had a mean age of 28.42 years (SD = 3.15), 55.2% were female, and 24.1% self-identified as Caucasian. Participants were grouped into ten teams of two to four residents and wore color-coded bracelets to identify them. Each team completed a single simulation scenario and had one appointed 'leader' and other residents acting in supporting roles (e.g., acting as a respiratory therapist or supporting physician).</p> <hd id="AN0180499035-10">Simulation context</hd> <p>Simulations were part of the medical residents' curriculum, and the research team had no control over the scheduling of the scenarios, selection of the participants, content, or duration of the simulations. These simulations were based on CRM training scenario scripts and used programmable high-fidelity manikins as "patients", which can mimic physiological activity (i.e., breath sounds, heart sounds, blinking, etc.). These high-fidelity manikins represent cutting-edge medical simulation technology and can be monitored for physiological activity as they interact with trainees through a speaker located in their mouth, controlled by a live simulation technician observing the simulation through a window. This simulation-based training environment allows medical learners to engage in simulated practice in a safe and controlled environment to advance their patient-care skills, in order to better acclimatize themselves to the rigors of medical practice. The simulation facilitators used standardized scripts for all simulations, which were designed in consultation with expert medical educators and practitioners. All the simulations were between 10 and 13 minutes long, which is approximately the average length of a CRM simulation.</p> <hd id="AN0180499035-11">Data collection</hd> <p>Prior to data collection, a member of our team explained the research study and provided information on consent to the residents. Once the residents were ready to enter the simulation room, the <emph>Empatica E4</emph> wristbands were placed on residents' wrists to capture their EDA signals, and they were asked to fill out a pre-simulation survey (Schuurmans et al., [<reflink idref="bib81" id="ref84">81</reflink>]). Simulation scenarios lasted approximately 10 min and were audio- and video-recorded using a multi-camera system in the simulation center. After the simulation, residents completed a debriefing session with a designated debriefer from the facilitation team, and filled out a post-simulation survey. The CRM simulation training was part of residents' standard medical education, but participation in this study was entirely voluntary and participation would not adversely affect trainees' ability to participate in future simulation training.</p> <hd id="AN0180499035-12">Tools</hd> <p>The following tools were used to analyze data:</p> <p></p> <ulist> <item> <bold> Coding scheme </bold> . Our coding scheme included codes for: 1) behaviors (posture and gestures, facial expression, and vocalics) and 2) regulation strategies, including SRL and SSRL​​​ which were then modified to fit a medically based research context​​​. Codes for behaviors and regulatory codes were made to be as explicit as possible to minimize the inferences that raters would have to make. A copy of the coding scheme has been included in Appendix 1 Table 6. The coding scheme is structured in the form of a superordinate code, a definition of that code, followed by an example of the code in a medical context. This is then followed by supporting levels of subordinate codes that are nested within the superordinate codes. This coding scheme borrowed established codes for SRL (C.2.1-C.2.6) (Hacker et al., [<reflink idref="bib37" id="ref85">37</reflink>]; Jansen et al., [<reflink idref="bib50" id="ref86">50</reflink>]; Zimmerman, [<reflink idref="bib92" id="ref87">92</reflink>]) and SSRL (C.3.1-C.3.2) (Grau & Whitebread, [<reflink idref="bib35" id="ref88">35</reflink>]; Hadwin & Järvelä, [<reflink idref="bib38" id="ref89">38</reflink>]; Hadwin & Oshige, [<reflink idref="bib40" id="ref90">40</reflink>]; Harley et al., [<reflink idref="bib42" id="ref91">42</reflink>], [<reflink idref="bib43" id="ref92">43</reflink>]; Hmelo-Silver & Barrows, [<reflink idref="bib44" id="ref93">44</reflink>]; Isohatala et al., [<reflink idref="bib47" id="ref94">47</reflink>]; Isohätälä et al., [<reflink idref="bib48" id="ref95">48</reflink>]; Järvenoja et al., [<reflink idref="bib57" id="ref96">57</reflink>]; Kwon et al., [<reflink idref="bib63" id="ref97">63</reflink>]; Lajoie et al., [<reflink idref="bib65" id="ref98">65</reflink>]; Lajoie & Lu, [<reflink idref="bib66" id="ref99">66</reflink>]; Lajoie et al., [<reflink idref="bib67" id="ref100">67</reflink>]; Lee et al., [<reflink idref="bib68" id="ref101">68</reflink>]; Panadero et al., [<reflink idref="bib76" id="ref102">76</reflink>]; Panadero & Järvelä, [<reflink idref="bib75" id="ref103">75</reflink>]; Sobocinski et al., [<reflink idref="bib82" id="ref104">82</reflink>]). Codes for social climate and participation (C.3.3-C.3.6)(Bass & Bass, [<reflink idref="bib8" id="ref105">8</reflink>]; Grau & Whitebread, [<reflink idref="bib35" id="ref106">35</reflink>]; Isohätälä et al., [<reflink idref="bib48" id="ref107">48</reflink>]; Kwon et al., [<reflink idref="bib63" id="ref108">63</reflink>]; Lajoie et al., [<reflink idref="bib65" id="ref109">65</reflink>]; Lee et al., [<reflink idref="bib68" id="ref110">68</reflink>]) were also included as these are often associated with team regulatory processes and group regulation within the literature (Bass & Bass, [<reflink idref="bib8" id="ref111">8</reflink>]; Grau & Whitebread, [<reflink idref="bib35" id="ref112">35</reflink>]; Isohätälä et al., [<reflink idref="bib48" id="ref113">48</reflink>]; Kwon et al., [<reflink idref="bib63" id="ref114">63</reflink>]; Lajoie et al., [<reflink idref="bib65" id="ref115">65</reflink>]; Lee et al., [<reflink idref="bib68" id="ref116">68</reflink>]). The coding of linguistics and vocalics (Appendix 2 Table 7, section B.2. Vocalics) were based on human rater judgments and drew from previous coding schemes (Eckland et al., [<reflink idref="bib28" id="ref117">28</reflink>]). Similarly, this composite coding scheme drew on existing codes that have worked to link behaviors to SRL and SSRL (D'Mello & Graesser, [<reflink idref="bib27" id="ref118">27</reflink>]; Frischen et al., [<reflink idref="bib32" id="ref119">32</reflink>]; Kazemitabar et al., [<reflink idref="bib58" id="ref120">58</reflink>], [<reflink idref="bib59" id="ref121">59</reflink>]). The research team used linguistic/vocalic codes to chart changes in the tone and timbre of how participants spoke and responded to each other, to compliment the gestures they enacted. By charting changes to the way participants spoke, it helped the research team describe how conversations, information, and directions were shared amongst members of a team. By linking posture, gestures, facial expressions, and vocalics to high-order constructs such as SRL and SSRL within a single time point or event, this coding scheme allowed researchers to conduct analyses that could describe how the presence of these behaviors describe complex regulatory patterns. Having these different coding channels aligned together permits analyses to be conducted in a way that allowed the research team to address their research questions. The codes were tested by the coding team using medical simulations and the researchers adjusted them based on input from researchers, simulation educators, and medical doctors, who provided expertise on healthcare-related questions.</item> <p></p> <item> <bold> Psychophysiological measurement </bold> . Measurement of EDA, specifically, skin conductance response (SCR), was collected using <emph>Empatica</emph> E4 bracelets. These bracelets are the approximate weight and dimensions of a smart-watch and provide researchers with the ability to collect psychophysiological data, including EDA, heart rate variability, skin temperature, and motion. Bracelets were given to medical trainees before they entered their simulations, and data was collected throughout the simulation. The devices were removed after the residents' debriefings were concluded.</item> </ulist> <hd id="AN0180499035-13">Analysis</hd> <p></p> <hd id="AN0180499035-14">Video coding</hd> <p>In the first iteration, researchers began by coding the team interactions of each video individually. The codebook contained codes for behaviors, SRL, and SSRL strategies that could be observed in the simulation recordings. Codes were iteratively adjusted to make them easier to use and more explicit in coding the target constructs. Three raters were trained in how to use the coding book, to ensure that any agreement/disagreement could be negotiated​. Raters were instructed to focus on coding the collaborative activities between the residents involved in the simulations. Amongst the raters, M.M. comes from a medical education research background, while S.L. and A.W. were undergraduate research assistants who received extensive training in conducting this coding. These perspectives on medical simulations provided the team with contrasting and complementary perspectives. In addition, input from our collaborative team of medical doctors and simulation educators allowed us to inquire and seek content-specific medical information that was needed to clarify interactions and events within the simulation videos.</p> <p>Raters coded videos individually, and then came together to negotiate the events that they observed during the 'Beginning', 'Escalation' and 'Peak' of each simulation, and the behavioral and regulatory strategies that were part of those events​. Segmentation of the simulation videos was conducted to organize the information from the simulations and create smaller units that can be analyzed. In addition, by creating defined segments, it allowed the researchers to make comparisons across groups based upon a particular portion of their simulation. These segments were decided based on consultation with the script of each simulation which acted as event markers for our analysis. We used the patient's deterioration and scripted events to guide the segmentation of data, for example, we may use the "patient's" sudden drop in pulse or the anaphylactic shock that tightens the airway to initiate the transition from the "Beginning" to the "Escalation" of a simulation. The segmentation of these videos was done to create segments that would be of comparable length and allow the researchers to identify the 'stakes' and what was expected of the medical trainees at any particular point of the simulation. Three segments ending with the 'Peak' were agreed upon in conjunction with medical doctors because often medical simulations do not have a 'resolution' as many end abruptly after the script has been completed or once the critical, life-saving tasks have been completed in order to make the trainees' learning as compact and timely as possible. The 'Peak' best represented the convergence of medical decision-making and the execution of simulated patient care, which the team felt comfortable coding. Differences in the events and codes were negotiated by observing the period in question jointly and re-examining the codes applied.</p> <p>Differences in the events and codes were negotiated by observing the period in question jointly and re-examining the codes applied. In total, ten (<emph>n</emph> = 10) simulations were coded, with a total of twenty-nine (<emph>N</emph> = 29) participants. Cohen's Kappas after the first negotiation are reported in Table 1 with ranges from 0.71 to 0.82 before deliberation, representing 'substantial' agreement between raters. Perfect agreement was reached after deliberation. All codes were calculated and presented as a frequency and percentage to indicate how many times a code appeared, and the percentage of overall codes that were present in that particular section of the simulation. For example, (15/0.30) would indicate that a particular code appeared 15 times, which accounts for 30% of all the codes for that segment of the scenario. The final and full frequency table can be seen in Appendix 2 Table 7.</p> <p>Table 1 Cohen's Kappa Calculations for Coded Simulations</p> <p> <ephtml> <table frame="hsides" rules="groups"><thead><tr><th align="left"><p>Simulation</p></th><th align="left"><p>Events both included</p></th><th align="left"><p>Events both exclude</p></th><th align="left"><p>Judge 1 included</p></th><th align="left"><p>Judge 2 included</p></th><th align="left"><p>Cohens' Kappa</p></th></tr></thead><tbody><tr><td align="left"><p>V1</p></td><td align="left"><p>10</p></td><td align="left"><p>2</p></td><td align="left"><p>1</p></td><td align="left"><p>0</p></td><td align="left"><p>0.75</p></td></tr><tr><td align="left"><p>V2</p></td><td align="left"><p>13</p></td><td align="left"><p>3</p></td><td align="left"><p>0</p></td><td align="left"><p>1</p></td><td align="left"><p>0.82</p></td></tr><tr><td align="left"><p>V3</p></td><td align="left"><p>18</p></td><td align="left"><p>4</p></td><td align="left"><p>1</p></td><td align="left"><p>1</p></td><td align="left"><p>0.75</p></td></tr><tr><td align="left"><p>V4</p></td><td align="left"><p>14</p></td><td align="left"><p>4</p></td><td align="left"><p>1</p></td><td align="left"><p>1</p></td><td align="left"><p>0.74</p></td></tr><tr><td align="left"><p>V5</p></td><td align="left"><p>12</p></td><td align="left"><p>3</p></td><td align="left"><p>1</p></td><td align="left"><p>0</p></td><td align="left"><p>0.81</p></td></tr><tr><td align="left"><p>V6</p></td><td align="left"><p>18</p></td><td align="left"><p>5</p></td><td align="left"><p>1</p></td><td align="left"><p>1</p></td><td align="left"><p>0.78</p></td></tr><tr><td align="left"><p>V7</p></td><td align="left"><p>15</p></td><td align="left"><p>3</p></td><td align="left"><p>1</p></td><td align="left"><p>1</p></td><td align="left"><p>0.71</p></td></tr><tr><td align="left"><p>V8</p></td><td align="left"><p>11</p></td><td align="left"><p>3</p></td><td align="left"><p>0</p></td><td align="left"><p>1</p></td><td align="left"><p>0.81</p></td></tr><tr><td align="left"><p>V9</p></td><td align="left"><p>14</p></td><td align="left"><p>2</p></td><td align="left"><p>1</p></td><td align="left"><p>0</p></td><td align="left"><p>0.77</p></td></tr><tr><td align="left"><p>V10</p></td><td align="left"><p>13</p></td><td align="left"><p>3</p></td><td align="left"><p>0</p></td><td align="left"><p>1</p></td><td align="left"><p>0.82</p></td></tr></tbody></table> </ephtml> </p> <hd id="AN0180499035-15">Physiological data analysis</hd> <p>Participants' EDA was collected using <emph>Empatica E4</emph> wristbands (Schuurmans et al., [<reflink idref="bib81" id="ref122">81</reflink>]). Participants wore the wristband before, during, and after the simulation scenarios. The <emph>Empatica E4</emph> wristband provides four data points per second (sampling rate: 4 Hz) measured in micro-Siemens (uS). All the EDA recordings were visually inspected in the Empatica platform to explore the integrity of the signals and to identify artifacts or data loss (Tomashin et al., [<reflink idref="bib84" id="ref123">84</reflink>]). Finally, data was preprocessed using the Ledalab function (version V3.4.9) from MATLAB (version R2023a) by applying a Butterworth low-pass filter with a lower cut-off frequency of 0.03 Hz to attenuate high-frequency noise allowing us to account for participant movement, and finally, manually removing artifacts using the linear interpolation method (Benedek & Kaernbach, [<reflink idref="bib10" id="ref124">10</reflink>]; Dindar et al., [<reflink idref="bib24" id="ref125">24</reflink>]; Kazi et al., [<reflink idref="bib60" id="ref126">60</reflink>]; Liu et al., [<reflink idref="bib70" id="ref127">70</reflink>]; Pijeira-Díaz et al., [<reflink idref="bib77" id="ref128">77</reflink>]).</p> <p>The research team chose to examine SCRs as part of the physiological analysis to address the research question that was asked. Continuous Decomposition Analysis (CDA) was the selected method for SCR extraction (Benedek & Kaernbach, [<reflink idref="bib10" id="ref129">10</reflink>]; Boucsein, [<reflink idref="bib14" id="ref130">14</reflink>]). This approach is effective in stopping noise and superimposed SCRs which could result in inaccuracies (Benedek & Kaernbach, [<reflink idref="bib10" id="ref131">10</reflink>]). A threshold of 0.05 μS was set for identifying SCRs, aligning with literature (Boucsein, [<reflink idref="bib14" id="ref132">14</reflink>]; Horvers et al., [<reflink idref="bib45" id="ref133">45</reflink>]). To account for EDA latency, a 3-s delay was used to account for the time between the onset of a stimulus response and the physiological response measured by the EDA (Boucsein, [<reflink idref="bib14" id="ref134">14</reflink>]). Using the 3-s delay helped to ensure more accurate alignment between the stimuli of the simulation and the physiological responses recorded, contributing to the precision and reliability of the analysis. Physiological activation during the simulation was quantified using a moving window width of 5 s and a moving step of 1 s (Pijeira-Díaz et al., [<reflink idref="bib78" id="ref135">78</reflink>]; Törmänen et al., [<reflink idref="bib86" id="ref136">86</reflink>]). This method captured the dynamic shifts in the EDA of trainees during the simulation segments. A 5-s window was chosen to observe SCR changes and to align with the segmentation of the simulation. Continuous and more accurate assessment was ensured by a 1-s step. The frequency of SCRs within each 5-s window was calculated, and the window was then shifted by 1 s in the following segment. This allowed for the average peaks per segment (APPS) to be determined, which was used to analyze the EDA data.</p> <hd id="AN0180499035-16">Power analysis</hd> <p>Using <emph>GPower</emph> 3.1(Faul et al., [<reflink idref="bib30" id="ref137">30</reflink>]), a retrospective power analysis indicated that an effect size of 0.70, an error probability of 0.05, a total sample of 29, with 10 teams, data at 3 time-points collected, and a correlation of 0.5 amongst measures, produces a nominal power of 0.75. Results indicate that this sample is sufficiently powered to meet statistical assumptions.</p> <hd id="AN0180499035-17">Statistical analysis</hd> <p>Data was analyzed using IBM SPSS Version 28 and STATA 18.</p> <hd id="AN0180499035-18">Results</hd> <p></p> <hd id="AN0180499035-19">Research question #1</hd> <p>When coding for the team-regulation responses, the raters indicated that the 'Beginning' of simulations required team-regulation codes that involved 'C.2.1.a. Hypothesizing' and 'C.2.1.b. Identifying/repeating important information', which were critical to establishing the patient's condition, and 'C.2.1.e. establishing givens in a task', which could have varied between simulations. For example, in the third simulation (V3; Appendix 1 Table 6), the simulation consisted of a leader and a resident team member, along with a nurse who was a confederate, which indicates that they are a medical professional who is 'acting' as the role of a nurse as part of the simulation script. The leader began by asking their team member and the nurse to examine the patient 'identifying important information' (7% of all the codes in the simulation section). The team member reported back 'establishing givens in a task '(20% of all the codes in the simulation section) that the patient had a particularly difficult intubation (that was conducted prior to the residents entering the simulation, per the script) and that the patient had visible swelling in their throat. This required the other team member to intervene in stopping swelling while the leader collected information from their team member and nurse regarding whether or not the swelling was causing difficulties in breathing. During this segment of the simulation, the leader experienced 3.89 APPS (APPS[average peaks per segment] was our unit of analysis for EDA) while their team member experienced a lower 0.25 APPS during the same segment, highlighting the differences in their EDA response.</p> <p>At the scenario's 'Escalation', complexities of the patient and deterioration tended to be observed. This required the team to 'C.2.4.c. Checking for self-understanding' (i.e., confirm that they had accurately collected the correct information in the initial diagnosis), and 'C.2.4.f. Noticing unfamiliar ideas or gaps in knowledge' that were caused by this situation. The leader and team had to communicate and form a plan by sharing their hypotheses regarding the patient's diagnosis. This is well illustrated within the fourth simulation (V4; Appendix 1 Table 6) where the leader had made the decision to intubate a patient to open their airway after other attempts to do so were ineffective. The simulation consisted of a leader and a resident team member, along with a nurse and a surgeon who were both confederates. This decision was made through 'establishing givens in a task' (2% of all the codes in the simulation section) and trying several intermediary interventions including oxygenating the patient and probing to examine if the patient's airway was being blocked by an obstruction, requiring the team to 'C.2.4.c. Check for self-understanding' (8% of all the codes in the simulation section). The formation of this decision was made as a group which required a 'C.3.5.c. Democratic leadership style' (7% of all the codes in the simulation section), with the leader producing the final decision and ultimately, final responsibility of the decision, through team input all the while using pro-social language (C.3.5.a. Referring to the team using plural and inclusive pronouns; e.g. we; 7% of all the codes in the simulation section) with their team. From this, the leader experienced 3.5 APPS compared to 2.92 APPS from their team member.</p> <p>During the 'Peak' of the simulation, members worked on critical tasks, which required 'C.2.2.f. Allocating tasks or roles to individuals or the team' on the part of the leader to ensure that all high-priority tasks were delegated in order to encourage team cohesion and assure the delivery of critical care to the patient. Team members 'C.2.5.e. Summarising or using analogues after a task' after completing tasks to ensure the bi-directional flow of information to and from leadership, and that was critical to ensure that split-second decisions could be dealt with by the team. A clear example of this was the seventh simulation (V7; Appendix 1 Table 6) where the patient was experiencing chest pains and an irregular heartbeat. The simulation consisted of a leader and a resident team member, along with 2 nurses who were both confederates. The team had collected prior information by 'C.2.1.b. Identifying important information'(3% of all the codes in the simulation section) and tried to stabilize them through administering epinephrine. With little warning, the patient moved into cardiac arrest despite their intervention. The leader had to act on standard protocols and ordered the team members to prepare to stabilize the patient and defibrillate them, during which the leader experienced 4.5 APPS and the team member 4.0 APPS. The defibrillation had to be planned and correctly orchestrated or else they would kill the patient. Information on the patient's status coming from multiple nurses had to be to the leader, and the leader's decision making needed to be conveyed clearly in a timely manner by 'C.2.2.f. Allocating tasks to individuals in the team' (11% of all the codes in the simulation section) in order to save the patient. The elevated physiological response from both the leader and team member could be indicative of the increased work-load and tasks needed to complete this critical care in the patient, as well as the increased coordination needed to execute this task. These are case examples of the different actions that both leaders and team members need to develop as part of medical simulations. The technical skills developed in individual practice need to be tested in team settings along with communication and teamwork skills that will be essential for success.</p> <p>Once videos were coded and the frequency of codes was compiled, a repeated measures ANOVA was performed to compare how the segment of the simulation ('Beginning', 'Escalation', and 'Peak' of the simulation) had an effect on the number of SRL and SSRL codes. For SRL codes, there was a statistically significant difference in the percentage of 'Execution' (<emph>F</emph>(<reflink idref="bib2" id="ref138">2</reflink>, 22) = 4.54, <emph>p</emph> = 0.01), and 'Evaluation' codes (<emph>F</emph>(<reflink idref="bib2" id="ref139">2</reflink>, 22) = 3.87, <emph>p</emph> = 0.03), and for SSRL codes, there was a statistically significant difference in the number of 'Facilitation' codes (<emph>F</emph>(<reflink idref="bib2" id="ref140">2</reflink>, 22) = 8.40, <emph>p</emph> < 0.001). Examining the pairwise comparisons to see where statistically significant differences emerged, with 'Execution' codes, there were differences between 'Beginning' and 'Escalation' (<emph>p</emph> < 0.0001, 95% CI [-3.66, -0.98]) and 'Beginning' and 'Peak' (<emph>p</emph> = 0.03, 95% CI [-5.43, -0.39]). With 'Evaluation' codes, there were differences between 'Beginning' and 'Peak' (<emph>p</emph> = 0.03, 95% CI [-2.69, -0.13]), and with 'Facilitation' codes, there were differences between 'Beginning' and 'Escalation' (<emph>p</emph> = 0.01, 95% CI [-1.77, -0.24]), and 'Beginning' and 'Peak' (<emph>p</emph> = 0.03, 95% CI [-1.67, -0.06]) (Table 2). The mean-percentage of codes for each of these categories are represented in Table 3.</p> <p>Table 2 Pairwise comparisons for SRL and SSRL Codes</p> <p> <ephtml> <table frame="hsides" rules="groups"><thead><tr><th align="left" rowspan="2"><p>Regulation Strategy</p></th><th align="left" rowspan="2"><p>(I) Execution</p></th><th align="left" rowspan="2"><p>(J) Execution</p></th><th align="left" rowspan="2"><p>Mean Difference (I-J)</p></th><th align="left" rowspan="2"><p>Std. Error</p></th><th align="left" rowspan="2"><p>Sig</p></th><th align="left" colspan="2"><p>95% CI</p></th></tr><tr><th align="left"><p>LL</p></th><th align="left"><p>UL</p></th></tr></thead><tbody><tr><td align="left"><p>Execution</p></td><td align="left"><p>Beginning</p></td><td align="left"><p>Escalation</p></td><td char="." align="char"><p>-2.32*</p></td><td char="." align="char"><p>0.64</p></td><td char="." align="char"><p>0.00</p></td><td char="." align="char"><p>-3.66</p></td><td char="." align="char"><p>-0.98</p></td></tr><tr><td align="left" /><td align="left" /><td align="left"><p>Peak</p></td><td char="." align="char"><p>-2.90*</p></td><td char="." align="char"><p>1.21</p></td><td char="." align="char"><p>0.03</p></td><td char="." align="char"><p>-5.43</p></td><td char="." align="char"><p>-0.39</p></td></tr><tr><td align="left" /><td align="left"><p>Escalation</p></td><td align="left"><p>Beginning</p></td><td char="." align="char"><p>2.32*</p></td><td char="." align="char"><p>0.64</p></td><td char="." align="char"><p>0.00</p></td><td char="." align="char"><p>0.98</p></td><td char="." align="char"><p>3.66</p></td></tr><tr><td align="left" /><td align="left" /><td align="left"><p>Peak</p></td><td char="." align="char"><p>-0.59</p></td><td char="." align="char"><p>1.12</p></td><td char="." align="char"><p>0.60</p></td><td char="." align="char"><p>-2.91</p></td><td char="." align="char"><p>1.73</p></td></tr><tr><td align="left" /><td align="left"><p>Peak</p></td><td align="left"><p>Beginning</p></td><td char="." align="char"><p>2.90*</p></td><td char="." align="char"><p>1.21</p></td><td char="." align="char"><p>0.03</p></td><td char="." align="char"><p>0.39</p></td><td char="." align="char"><p>5.43</p></td></tr><tr><td align="left" /><td align="left" /><td align="left"><p>Escalation</p></td><td char="." align="char"><p>0.59</p></td><td char="." align="char"><p>1.12</p></td><td char="." align="char"><p>0.60</p></td><td char="." align="char"><p>-1.73</p></td><td char="." align="char"><p>2.91</p></td></tr><tr><td align="left"><p>Evaluation</p></td><td align="left"><p>Beginning</p></td><td align="left"><p>Escalation</p></td><td char="." align="char"><p>-0.64</p></td><td char="." align="char"><p>0.44</p></td><td char="." align="char"><p>0.49</p></td><td char="." align="char"><p>-1.78</p></td><td char="." align="char"><p>0.51</p></td></tr><tr><td align="left" /><td align="left" /><td align="left"><p>Peak</p></td><td char="." align="char"><p>-1.41*</p></td><td char="." align="char"><p>0.49</p></td><td char="." align="char"><p>0.03</p></td><td char="." align="char"><p>-2.69</p></td><td char="." align="char"><p>-0.13</p></td></tr><tr><td align="left" /><td align="left"><p>Escalation</p></td><td align="left"><p>Beginning</p></td><td char="." align="char"><p>0.64</p></td><td char="." align="char"><p>0.44</p></td><td char="." align="char"><p>0.49</p></td><td char="." align="char"><p>-0.51</p></td><td char="." align="char"><p>1.78</p></td></tr><tr><td align="left" /><td align="left" /><td align="left"><p>Peak</p></td><td char="." align="char"><p>-0.77</p></td><td char="." align="char"><p>0.58</p></td><td char="." align="char"><p>0.59</p></td><td char="." align="char"><p>-2.28</p></td><td char="." align="char"><p>0.74</p></td></tr><tr><td align="left" /><td align="left"><p>Peak</p></td><td align="left"><p>Beginning</p></td><td char="." align="char"><p>1.41*</p></td><td char="." align="char"><p>0.49</p></td><td char="." align="char"><p>0.03</p></td><td char="." align="char"><p>0.13</p></td><td char="." align="char"><p>2.69</p></td></tr><tr><td align="left" /><td align="left" /><td align="left"><p>Escalation</p></td><td char="." align="char"><p>0.77</p></td><td char="." align="char"><p>0.58</p></td><td char="." align="char"><p>0.59</p></td><td char="." align="char"><p>-0.74</p></td><td char="." align="char"><p>2.28</p></td></tr><tr><td align="left"><p>Facilitation</p></td><td align="left"><p>Beginning</p></td><td align="left"><p>Escalation</p></td><td char="." align="char"><p>-1.00*</p></td><td char="." align="char"><p>0.29</p></td><td char="." align="char"><p>0.01</p></td><td char="." align="char"><p>-1.77</p></td><td char="." align="char"><p>-0.24</p></td></tr><tr><td align="left" /><td align="left" /><td align="left"><p>Peak</p></td><td char="." align="char"><p>-0.86*</p></td><td char="." align="char"><p>0.31</p></td><td char="." align="char"><p>0.03</p></td><td char="." align="char"><p>-1.67</p></td><td char="." align="char"><p>-0.06</p></td></tr><tr><td align="left" /><td align="left"><p>Escalation</p></td><td align="left"><p>Beginning</p></td><td char="." align="char"><p>1.00*</p></td><td char="." align="char"><p>0.29</p></td><td char="." align="char"><p>0.01</p></td><td char="." align="char"><p>0.24</p></td><td char="." align="char"><p>1.77</p></td></tr><tr><td align="left" /><td align="left" /><td align="left"><p>Peak</p></td><td char="." align="char"><p>0.14</p></td><td char="." align="char"><p>0.41</p></td><td char="." align="char"><p>1.00</p></td><td char="." align="char"><p>-0.92</p></td><td char="." align="char"><p>1.20</p></td></tr><tr><td align="left" /><td align="left"><p>Peak</p></td><td align="left"><p>Beginning</p></td><td char="." align="char"><p>0.86*</p></td><td char="." align="char"><p>0.31</p></td><td char="." align="char"><p>0.03</p></td><td char="." align="char"><p>0.06</p></td><td char="." align="char"><p>1.67</p></td></tr><tr><td align="left" /><td align="left" /><td align="left"><p>Escalation</p></td><td char="." align="char"><p>-0.14</p></td><td char="." align="char"><p>0.41</p></td><td char="." align="char"><p>1.00</p></td><td char="." align="char"><p>-1.20</p></td><td char="." align="char"><p>0.92</p></td></tr></tbody></table> </ephtml> </p> <p>Based on estimated marginal means *The mean difference is significant at the.05 level</p> <p>Table 3 Mean Percentage of SRL and SSRL Strategies</p> <p> <ephtml> <table frame="hsides" rules="groups"><thead><tr><th align="left"><p>Regulation Strategy</p></th><th align="left"><p>Simulation Segment</p></th><th align="left"><p><italic>M</italic></p></th><th align="left"><p><italic>SD</italic></p></th></tr></thead><tbody><tr><td align="left"><p>Execution</p></td><td align="left"><p>Beginning</p></td><td align="left"><p>0.037</p></td><td align="left"><p>2.94</p></td></tr><tr><td align="left" /><td align="left"><p>Escalation</p></td><td align="left"><p>0.067</p></td><td align="left"><p>3.50</p></td></tr><tr><td align="left" /><td align="left"><p>Peak</p></td><td align="left"><p>0.094</p></td><td align="left"><p>4.45</p></td></tr><tr><td align="left"><p>Evaluation</p></td><td align="left"><p>Beginning</p></td><td align="left"><p>0.01</p></td><td align="left"><p>1.77</p></td></tr><tr><td align="left" /><td align="left"><p>Escalation</p></td><td align="left"><p>0.02</p></td><td align="left"><p>2.03</p></td></tr><tr><td align="left" /><td align="left"><p>Peak</p></td><td align="left"><p>0.03</p></td><td align="left"><p>2.28</p></td></tr><tr><td align="left"><p>Facilitation</p></td><td align="left"><p>Beginning</p></td><td align="left"><p>0.013</p></td><td align="left"><p>1.74</p></td></tr><tr><td align="left" /><td align="left"><p>Escalation</p></td><td align="left"><p>0.031</p></td><td align="left"><p>2.80</p></td></tr><tr><td align="left" /><td align="left"><p>Peak</p></td><td align="left"><p>0.043</p></td><td align="left"><p>2.71</p></td></tr></tbody></table> </ephtml> </p> <hd id="AN0180499035-20">Research question #2</hd> <p>A multilevel model (MLM) analysis was conducted to determine whether the difference in psychophysiological activation during the different segments of a team-based medical simulation were significant. A mixed model was used with the segment of the simulation as the independent variable (IV), the simulation the participant was part of and the participant themselves as levels 1 and 2 of the model, with the EDA activation value (measured as the average peaks-per event) as the dependent variable (DV). Results indicated that there was a significant difference between residents' physiological activation in different segments of the medical simulation. Specifically, residents reported differing levels of EDA activation during different parts of the simulation (<emph>b</emph> = 13.28, <emph>p</emph> < 0.01) (Table 4). Descriptives of the average peaks per event are reported in Table 5.</p> <p>Table 4 Multilevel models of the effect of simulation segment on EDA</p> <p> <ephtml> <table frame="hsides" rules="groups"><thead><tr><th align="left" /><th align="left"><p><italic>Null</italic></p></th><th align="left"><p><italic>Full model</italic></p></th></tr></thead><tbody><tr><td align="left"><p>Intercept</p></td><td align="left"><p>0.18**</p></td><td char="." align="char"><p>1.43**</p></td></tr><tr><td align="left"><p>Time</p></td><td align="left" /><td char="." align="char"><p>1.43</p></td></tr><tr><td align="left"><p>Variance components</p></td><td align="left" /><td char="." align="char" /></tr><tr><td align="left"><p>Simulation</p></td><td align="left" /><td char="." align="char"><p> < 0.001</p></td></tr><tr><td align="left"><p>Participant</p></td><td align="left" /><td char="." align="char"><p> < 0.001</p></td></tr><tr><td align="left"><p>ICCs</p></td><td align="left"><p>0.11</p></td><td char="." align="char" /></tr><tr><td align="left"><p>ICC<sub>P>s</sub></p></td><td align="left"><p>0.19</p></td><td char="." align="char" /></tr></tbody></table> </ephtml> </p> <p>*<emph>p</emph> < 0.05, **<emph>p</emph> < 0.00 The variance components represent the random effects of the model. Team variance refers to the variance estimate at the team level. ICCS refers to the intraclass coefficient for the team level. Participant variance refers to the variance estimate at the participant level. ICC<subs>P>S</subs> refers to the intraclass coefficient for the participant level nested within the team level</p> <p>Table 5 Mean Number of Average Peaks per Segment during the Simulation</p> <p> <ephtml> <table frame="hsides" rules="groups"><thead><tr><th align="left"><p>Segment of Simulation</p></th><th align="left"><p><italic>N</italic></p></th><th align="left"><p><italic>M</italic></p></th><th align="left"><p><italic>SD</italic></p></th></tr></thead><tbody><tr><td align="left"><p>Beginning</p></td><td align="left"><p>29</p></td><td align="left"><p>1.56</p></td><td align="left"><p>1.11</p></td></tr><tr><td align="left"><p>Escalation</p></td><td align="left"><p>29</p></td><td align="left"><p>2.48</p></td><td align="left"><p>1.36</p></td></tr><tr><td align="left"><p>Peak</p></td><td align="left"><p>29</p></td><td align="left"><p>4.42</p></td><td align="left"><p>1.88</p></td></tr></tbody></table> </ephtml> </p> <hd id="AN0180499035-21">Discussion</hd> <p></p> <hd id="AN0180499035-22">Implications for theory</hd> <p>Examining our results, there were statistically significant differences in the mean-level of activation that medical trainees experienced between the 'Beginning', 'Escalation', and 'Peak' of their medical simulations. These suggest that as the simulation progressed, members of the team began to be more stimulated. These findings could align with Bond ([<reflink idref="bib13" id="ref141">13</reflink>]) and Dias ([<reflink idref="bib23" id="ref142">23</reflink>]) by suggesting that varying levels of physiological activation do occur as a result of the demands placed on medical trainees as they manage a case. During the "Beginning" phase of the simulation, the residents are usually faced with collecting information from the patient, understanding any underlying conditions, and becoming familiar with the parameters of the case. All of these could require less physiological activation due to lower cognitive demands. As the residents move into the "Escalation" phase, they are faced with having to work in tandem with other residents, and thus require teamwork skills, as well as a capacity for more complex medical management including running tests, centralizing information, and making a correct plan of treatment. Undoubtedly, this stage would place greater cognitive demands on the medical trainee, resulting in increased physiological activation. Finally, the 'Peak' of the simulation would require the most engagement, as the trainees are required to execute their plan to ensure patient survival and/or success in the objectives. The increased activation seen as the simulations progress would fit with our understanding of psychophysiological responses and the challenges that come from an active performance.</p> <p>When examining the regulatory codes that medical trainees displayed, similar patterns can be seen in how the demands of the simulation change the regulatory needs of the team. When examining the 'execution' codes across the different periods of the simulation, we saw that there were differences in the number of codes between the 'Beginning' and the 'Peak', and between the 'Beginning' and the 'Escalation'. Applying the COPES model from Winnie and Hadwin ([<reflink idref="bib89" id="ref143">89</reflink>]), the third phase, 'Performance', indicates that individuals move forward in a task, they do not plan but execute their planned strategy. In a simulation, the differences in the use of execution strategies between the "Beginning" and 'Escalation' phase would suggest that as the simulation became more demanding, when residents needed to execute their plan of treatment and rally the necessary resources, the trainees required regulatory strategies to help deliver patient care. The lack of statistical significance between the 'Escalation' and the 'Peak' could suggest that the trainees already move into a cycle of engaging in effective execution strategies during 'Escalation' and continue with them through the 'Peak' of the task. Within the fourth phase of COPES, 'Evaluation', this phase necessitates the need for assessing the effectiveness, or lack of, of the strategy(s) just employed. In this stage, learners evaluate their performance and the success or failure of the goal. The differences seen in the frequency of these codes mirror those of the 'Execution' codes by suggesting that residents need to engage in more metacognitive evaluation to assess their own regulation and the effectiveness of the plan that was just executed.</p> <p>Similarly, the 'Facilitation' codes seen between the "Beginning" and 'Escalation', and the "Beginning" and the 'Peak' differed, but no such statistical differences were seen between the 'Escalation' and 'Peak'. These SSRL codes focus on regulating the team by sharing new information, changing the climate of the team, and helping to make the team an operational success. The presence of 'Facilitation' codes could be used to indicate the 'monitoring' and 'controlling' facets of the COPES model (Winne & Hadwin, [<reflink idref="bib89" id="ref144">89</reflink>]) as a result of how they function within the context of the medical simulation. The use of codes to describe the 'controlling' and 'monitoring' phases of COPES facilitate team members to move between monitoring the products and success of their medical treatment, and how team members are examining the standards of care and the plan that they have established. At the 'Beginning' segment of the simulation, teams were working to establish the standards of the task, which would involve examining the patient and executing the appropriate exams or tests to determine the patient's condition, while at the same time requiring potentially unfamiliar team members to establish pro-social emotional interactions and dialogue that they needed to complete that task. Codes such as "C.3.1.a. Activating the team with a new construct or idea in line with previous direction/action taken" and "C.3.1.b. Confirm that the previous direction was correct" are examples of 'Facilitation' codes that required team members to effectively monitor the success, or lack of success, that the team is having while completing a clinical task and to communicate how those findings would affect future decision making in the case. Similarly, the team members required more 'Facilitation' codes at the end of the task, to monitor and assess the team's collective task understanding of how they had delivered their course of treatment The use of these regulatory codes fit into the 'controlling' and 'monitoring' facets of COPES by aiding team members in moving between monitoring the products and success of their medical treatment, and examining how team members are meeting their plan for the standards of care that they have established. The reason for the differences in the frequency of codes seen could be similar to the effect seen in the SRL 'Execution' codes, which could suggest that as the medical trainees move through the simulation, they require more regulation strategies such 'C.2.3.a. Commenting on explanation', 'C.2.3.b. Reacting to a questioner', 'C.2.3.c. Estimating', or 'C.2.3.e. Executing a plan or a procedure', needed in the task. As trainees move from the 'Beginning' to 'Escalation' of the scenario, they need to start using these strategies to create a cohesive team, but once they start using these strategies, they do not statistically differ through to the 'Peak' of the simulation. These findings advance our understanding of SRL and SSRL theory by indicating that the regulatory needs of individuals and teams change throughout different sections of a simulation to meet the contextual needs of simulated medical care. The strategies employed to assess patients are not the strategies that are needed to regulate an individual and their team as they are forced to execute complex decision making. These results highlight how the COPES model could be used in conjunction with a coding scheme to describe how team members' regulation strategies describe theory-driven models of regulation. In addition, this contributes to our understanding of the various metacognitive regulation strategies needed within medical simulation training and how medical trainees must learn to master them to become effective practitioners in medical teams.</p> <p>Examining the psychophysiological results from this study, these findings support the work of Törmänen ([<reflink idref="bib86" id="ref145">86</reflink>]) by suggesting that increases in physiological activation within team members can perhaps predicate the need for more team regulatory mechanisms between team members. As seen in this current study, as the activation of team members entered the more critical 'Escalation' and 'Peak' of the simulations, this necessitated members to use more SSRL skills as they helped to plan and execute complex medical interventions, coinciding with increased activation. These findings add to the sparce literature on psychophysiological arousal and activation within educational psychology and medical education by providing indicators of how increased activation in medical trainees can be accompanied by changes to their regulation. This provides the basis for further research into how individual regulatory strategies may be preceded by physiological responses, and more nuanced examinations into theories that surround this topic.</p> <hd id="AN0180499035-23">Implications for methodology</hd> <p>This study advances our methodological understanding of the integration of psychophysiology and self-regulation within a high-fidelity medical simulation. The integration of regulatory coding and accompanying psychophysiological activation advances our understanding of how these two streams of data can be used together to provide a deeper examination into group regulation in medical simulation settings. Importantly, our findings provide a compelling rationale for the integration of physiological monitoring into medical education, as also suggested by previous research (Arora et al., [<reflink idref="bib3" id="ref146">3</reflink>]; Bond et al., [<reflink idref="bib13" id="ref147">13</reflink>]; Dias & Scalabrini-Neto, [<reflink idref="bib23" id="ref148">23</reflink>]; Doulougeri et al., [<reflink idref="bib26" id="ref149">26</reflink>]; Grewal & Heather, [<reflink idref="bib36" id="ref150">36</reflink>]; Kharatzadeh et al., [<reflink idref="bib61" id="ref151">61</reflink>]; Maher et al., [<reflink idref="bib71" id="ref152">71</reflink>]). The unique, technology-immersive environment of high-fidelity medical simulations provides a new setting for examining how team-regulation occurs and how it can affect learner responses. By integrating physiological feedback into the study of how SRL and SSRL occurs for medical trainee teams, this work hopes to add further depth into the study of learner performance in a high-tech, simulation-based environment.</p> <hd id="AN0180499035-24">Implications for practice</hd> <p>Practically, this work also adds to the growing body of literature on the exploration of SRL and SSRL within medical education settings (Bransen et al., [<reflink idref="bib16" id="ref153">16</reflink>], [<reflink idref="bib17" id="ref154">17</reflink>]), and provides further evidence for the growing importance that is placed on developing medical trainees' regulatory abilities for professional knowledge and skill development. The incorporation of emotion regulation training as part of medical curriculums would enhance performance by equipping medical residents with effective emotion regulation strategies, and by attenuating the negative effects of stress on residents' learning, performance, and overall well-being, both in the short and long term. Research has stressed the importance of emotional well-being and the need for regulatory training as part of the medical curriculum(Artino & Naismith, [<reflink idref="bib6" id="ref155">6</reflink>]; Artino & Pekrun, [<reflink idref="bib5" id="ref156">5</reflink>]). These findings provide indicators that the behaviors and psychophysiological responses of medical trainees can hold valuable data into how they are developing their regulatory abilities, and how to monitor that progress as part of their professional growth. As has been seen, as medical learners' cognitive load increases and they are physiologically activated, teams may need to use more pro-social regulatory 'facilitation' strategies in addition to 'execution' and 'evaluation' strategies, in order to examine their own success. This data can be used in conjunction with debriefing as part of a feedback loop to help trainees identify and self-reflect on their regulatory skills and development.</p> <p>Examining the assigned roles of medical learners within simulation can provide us with suggestions for how SRL and SSRL processes can be managed. Leaders in medical simulations need to have the skills to collect, synthesize and act on the information given to them by their team. This type of role requires an individual to be able to regulate themselves in order to be able to listen and absorb multiple streams of information from team members, nurses, case-critical hardware, and other sources of patient information. In addition, the leader must be the center of maintaining the morale of the team; motivating, supporting, and driving the team to deliver the best possible outcome for the patient. Likewise, team members need to have the SRL skills needed to manage the stresses of hands-on patient care and the constant requirement to vocalize this information with the team. Both these roles require SRL and SSRL skills, but both roles have contrasting expectations to maximize the skills needed within a medical team. The findings of this study can be used as the point of departure for more focused research that can compare the differences between these two roles within medical simulations and how each may view the role of regulation as part of their medical training.</p> <p>The findings from this study can also benefit future debriefing of simulations. By referencing moments of increased SCR frequency, simulation facilitators can bring up this data in their debriefings to make medical trainees aware of their sympathetic arousal and to have a focused discussion to reflect on what they were doing during that part of the simulation that could warrant a heightened physiological response, as well as an accompanying discussion on how the trainee managed that episode within the simulation. This could be done on an individual basis, or on the team/dyad level to make residents aware of how differences in response occur between colleagues in a simulation. By making this data visible to trainees, it can help 'close the loop' on residents' learning in a simulation to help them identify how their physical response are impacted by their task and regulatory abilities.</p> <hd id="AN0180499035-25">Limitations, strengths, and future direction</hd> <p>It is important to acknowledge limitations to this study. Firstly, this study had a small sample size, and a larger sample size would increase the confidence in our findings and allow for broader generalizations to be made. In addition, a larger sample size would allow us to examine differences between trainees and leaders from different specialties and years of clinical training, and to question how more variations in controlling factors could affect results. A small sample size is a common limitation in studies involving highly specialized populations like medical residents, who have complex schedules and challenges that emerge in data collection, but this study was sufficiently powered to meet statistical assumptions. Nevertheless, the contribution of these findings in the context of CRM simulations should not be undermined (Kim et al., [<reflink idref="bib62" id="ref157">62</reflink>]), as the study of smaller-scale samples provides empirical validity to what has been studied. Additionally, our study design and recruitment practices limited our recruitment efforts to only the residents who were required to undergo CRM training as part of their curriculum; this limitation emerged because medical simulations are prohibitively expensive to independently conduct outside of research partners in such a highly specialized program such as that seen in medical residency. Despite the sample size and number of groups, the statistical power for the sample was achieved through a nominal power of 0.75, to indicate that the sample was sufficiently powered to meet the statistical assumptions of the MLM analysis. Like other medical simulation studies, we observed medical trainees completing a limited number of simulations, in a small number of specializations in the entirety of medicine, within one institution's training program. This limitation is similar to educational studies that examine a limited number of topics in mathematics education at one school, in a single district, for example. The use of MLM as a tool to account for differences at varying levels of the sample (including individual, teams, cohorts, etc.) represents an essential step towards acknowledging the differences that can impact final analysis in these research settings. This study makes a contribution to the field of multimodal, self-regulation research in medical education while acknowledging that future work must be done to study medical trainees in a broader range of environments, tasks they are completing, and differences in region and country.</p> <p>Given the circumstances of data collection with medical residents and the fact that residents are often moving between 2–4 medical simulations and debriefings within a short period of time, it is challenging for us to collect an EDA baseline due to time constraints with this group of participants. This was field research in an authentic educational activity where the research team played a mostly observational role. Unlike K-12 or higher education field or classroom-based research, medical trainees have medical responsibilities and extremely limited time to engage in this training. Medical trainees rarely have the opportunity to practice skills in a simulation center and, therefore, this time is especially rare because of the high demand from multiple programs across health professions education to place their trainees in such scenarios. The approach of using SCR as a measure of EDA, allowed the research team to enter this fast-paced environment and address the research question that was asked.</p> <p>The authors acknowledge that the output's Intraclass Correlation Coefficient (ICC) values were low indicating a small amount of variance as an effect of the levels in a model (O'Connell & McCoach, [<reflink idref="bib74" id="ref158">74</reflink>]). This data was nested at the individual, team, and simulation levels, to indicate the 'memberships' that participants were part of which could play a role in accounting for differences, as well as participants' exposure to each other before the simulation. Conducting a MLM allowed the research team to account for the grouping of team members as they worked together while completing these simulations together. Due to the uncertain availability of medical trainees' schedules to complete simulation training, some members of a team may have worked together while others may have meet each other for the first time. The research team did not ask about familiarity, professional or personal relationships between medical trainees because this was not logistically possible given the time constraints. The small ICC values do not discredit this analysis but the small variances that exist with this sample should be stated.</p> <p>For future steps in this research, there continues to be discussions surrounding the granularity of multimodal, mixed-method research (Azevedo & Gašević, [<reflink idref="bib7" id="ref159">7</reflink>]), as questions about the ability to 'link' multiple streams of data into a cohesive unit still remains. The segmentation of data, including the analysis of videos based on the 'Beginning', 'Escalation', and 'Peak' of the simulations as seen in this study, aligns with the needs of researchers and follows a common pattern seen in other simulations, which allows researchers and facilitators to understand the results. The ability to integrate psychophysiology and coded behaviors offer significant theoretical and methodological advancements to the study of regulation, but future study will continue to find ways to incorporate innovative tools such as artificial intelligence and machine learning systems to help deal with issues of data synchrony.</p> <p>In conclusion, our findings provide a novel insight into the utilization of physiological responses to discern the regulation strategies of teams in medical education. The practical insights gained provide researchers and medical educators with advancement in the understanding and importance of regulation in medical training, as well as clear future steps for continued training. The implications of our findings extend beyond medical education and educational psychology, as the application of these methods could have important implications for understanding and enhancing team collaboration and performance across various domains.</p> <hd id="AN0180499035-26">Acknowledgements</hd> <p>The authors thank the staff of the Steinberg Centre for Simulation and Interactive Learning (SCSIL), McGill University where data was collected.</p> <hd id="AN0180499035-27">Funding</hd> <p>This work was supported by the Social Sciences and Humanities Research Council of Canada Partnership Development Grant (Grant ID: 890–2020-0060) awarded to the senior author, J.M. Harley. </p> <hd id="AN0180499035-28">Data Availability</hd> <p>Data is not available due to being outside the scope of IRB approval and reflects a small, highly specialized professional population.</p> <hd id="AN0180499035-29">Declarations</hd> <p></p> <hd id="AN0180499035-30">Ethics approval</hd> <p>Internal Ethics Review Board approval was obtained from McGill University prior to the study beginning.</p> <hd id="AN0180499035-31">Competing interests</hd> <p>The authors declare that they have no known competing financial interests, personal relationships, or conflicts of interest that could have appeared to influence the work reported in this paper.</p> <hd id="AN0180499035-32">Consent to participate</hd> <p>Before collecting any data, all participants were informed about the study and their right to freely withdraw consent at any time during the data collection. Consent was obtained via a signature and written approval.</p> <hd id="AN0180499035-33">Appendix 1</hd> <p>Table 6</p> <p>Table 6 Coding book</p> <p> <ephtml> <table frame="hsides" rules="groups"><tbody><tr><td align="left"><p>B. BEHAVIOURAL OBSERVATIONS</p></td><td align="left"><p>Physical behaviors that are used to express or convey information and emotions. Includes facial expressions, body posture, gestures, and the use of space</p></td><td align="left"><p>B.1. ATTENTION TENDENCY</p></td><td align="left"><p>Use of perceived gaze direction to shift visual attention, that is, the seemingly automatic propensity to orient to the same object that other people are looking at</p></td><td align="left"><p>The team leader asks to the patient: "Any difficulty breathing? She moves to her righ t to look at the monitor and says: " she's saturating over 90, well?" then goes back to her position</p></td><td align="left"><p>B.1.a. Gaze directed towards the patient</p></td><td align="left"><p>The chief medical trainee looks towards the patient as they read out the results of bloodwork</p></td><td align="left" /><td align="left" /></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>B.1.b. Gaze directed towards an information source (monitor, medical devices, medical chart, person providing information)</p></td><td align="left"><p>The medical trainee looks at the EKG to examine the patient's heartrate</p></td><td align="left" /><td align="left" /></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>B.1.c. Gaze directed away of the patient, information source, member of the team/directed outside of the room</p></td><td align="left"><p>The chief medical trainee looks outside the examination room as the RT comes in to help the patient</p></td><td align="left" /><td align="left" /></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>B.1.d. Gaze directed towards other members of the team</p></td><td align="left"><p>When eliciting information from the team, the chief medical trainee looks at all members of the team to get their opinion of the diagnosis</p></td><td align="left" /><td align="left" /></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>B.1.e. Gaze directed downward</p></td><td align="left"><p>The medical trainee looks down as the stress of the task becomes overwhelming</p></td><td align="left" /><td align="left" /></tr><tr><td align="left" /><td align="left" /><td align="left"><p>B.2. VOCALICS</p></td><td align="left"><p>Vocal characteristics refer to implicit paralinguistic features of speech, which provided an enriching passage to infer the emotional states of the subjects</p></td><td align="left"><p>The team leader in charge of talking to the patient, in a grave tone, says to the team leader "I noticed that the pt is not responding to me...." Then asks the pt:(increases his volume and pitch) "How do you feel now?" He leans in getting closer to the patient's head </p></td><td align="left"><p>B.2.1. VOLUME OF SPEECH</p></td><td align="left"><p>The perceived loudness of the speaker</p></td><td align="left"><p>B.2.1.a. Silent</p></td><td align="left"><p>The medical trainee does not say anything</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>B.2.1.b. Normal</p></td><td align="left"><p>The medical trainee speaks at a conversational voice</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>B.2.1.c. Increased</p></td><td align="left"><p>The medical trainee speaks loudly, as to project and be heard over the team</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>B.2.1.d. Decreased</p></td><td align="left"><p>The medical trainee speaks at a quieter voice</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>B.2.2. SPEED OF SPEECH</p></td><td align="left"><p>The speed at which someone speaks. It's calculated in the number of words spoken in a minute (wpm.)</p></td><td align="left"><p>B.2.2.a. Normal</p></td><td align="left"><p>The medical trainee speaks at a normal conversational voice</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>B.2.2.b. Slow</p></td><td align="left"><p>The medical trainee speaks slower than during a conversation</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>B.2.2.c. Fast</p></td><td align="left"><p>The medical trainee speaks faster than a normal conversational voice</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>B.2.3. VERBAL FILLERS ("um," "uh," "like," and "ah")</p></td><td align="left"><p>The not-so-meaningful words used to fill the gaps in the speech</p></td><td align="left"><p>B.2.3.a. Hesitance/ Insecurity/Trembling</p></td><td align="left"><p>The medical trainee starts visibly trembling or shaking</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>B.2.3.b. Substitution while thinking</p></td><td align="left"><p>The residnet starts using a number of 'ums' or 'ahs' in their speech</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>B.2.4. PITCH OF SPEECH</p></td><td align="left"><p>the relative highness or lowness of a tone as perceived by the ear, which depends on the number of vibrations per second produced by the vocal cords </p></td><td align="left"><p>B.2.4.a. High pitch</p></td><td align="left"><p>The medical trainee raises the pitch of their voice</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>B.2.4.b. Low pitch</p></td><td align="left"><p>The medical trainee lowers the pitch of their voice</p></td></tr><tr><td align="left" /><td align="left" /><td align="left"><p>B.3. BODILY EXPRESSION</p></td><td align="left"><p>Body language is a range of nonverbal signals that can be use to communicate emotions and intentions. These include posture, facial expressions, and hand gestures </p></td><td align="left" /><td align="left"><p>B.3.1. FACIAL EXPRESSION</p></td><td align="left"><p>Movement of facial muscles to emote</p></td><td align="left"><p>B.3.1.a. Smiling</p></td><td align="left"><p>The medical trainee smiles</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>B.3.1.b. Unilateral brow lift</p></td><td align="left"><p>The medical trainee raises their eyebrow</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>B.3.1.c. Bilateral brow lift</p></td><td align="left"><p>The medical trainee raises both their eyebrows</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>B.3.1.d. Focusing eyes</p></td><td align="left"><p>The medical trainee squints and focuses their gaze</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>B.3.2. HEAD</p></td><td align="left"><p>Movement of the head in its direction</p></td><td align="left"><p>B.3.2.a. Nodding</p></td><td align="left"><p>The medical trainee nods their head</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>B.3.2.b. Light head bow</p></td><td align="left" /></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>B.3.2.c. Back and forth headshake (no)</p></td><td align="left"><p>The medical trainee moves their head back and forth</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>B.3.2.d. Lateral Head tilt</p></td><td align="left"><p>The medical trainee tilts their head</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>B.3.2.e. Looking away</p></td><td align="left"><p>The medical trainee looks away from the direction or person they are looking at</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>B.3.2.f. Looking back and forth</p></td><td align="left"><p>The medical trainee looks back and forth</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>B.3.2.g. Chin up</p></td><td align="left"><p>The medical trainee raises their chin</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>B.3.2.h. Chin down</p></td><td align="left"><p>The medical trainee lowers their chin</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>B.3.3. SHOULDERS</p></td><td align="left"><p>Movement of shoulders</p></td><td align="left"><p>B.3.3.a. Bilateral shrug</p></td><td align="left"><p>The medical trainee moves both their shoulders</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>B.3.3.b. Unilateral shrug</p></td><td align="left"><p>The medical trainee moves one of their shoulders</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>B.3.4. HANDS</p></td><td align="left"><p>Movement of hands</p></td><td align="left"><p>B.3.4.a. Expressing with hands (Illustrator, emblems)</p></td><td align="left"><p>The medical trainee actively emotes with their hands</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>B.3.4.b. Fidgeting:Touching own face/hair/hands</p></td><td align="left"><p>The medical trainee touches their face</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>B.3.4.c. Hands on hips elbows out</p></td><td align="left"><p>The medical trainee places their hands in their hips</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>B.3.4.d. Hands on pockets elbows in/ Hands clasped/arms crossed</p></td><td align="left"><p>The medical trainee places their hands in their pocket</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>B.3.5. STANDING POSTURE (At rest/Relative to peers/patient)</p></td><td align="left"><p>Posture of the individual in relationship to team mates and patient</p></td><td align="left"><p>B.3.5.a. Changing position/balancing</p></td><td align="left"><p>The medical trainee changes their standing position, or starts leaning on objects</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>B.3.5.b. Withdrawn</p></td><td align="left"><p>The medical trainee leans back</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>B.3.5.c. Leaning in</p></td><td align="left"><p>The medical trainee leans in</p></td></tr></tbody></table> </ephtml> </p> <p> <ephtml> <table frame="hsides" rules="groups"><tbody><tr><td align="left"><p>C. REGULATORY MECHANISIMS</p></td><td align="left"><p>A combination of emotional, self-regulatory and social/co-regulation strategies</p></td><td align="left"><p>C.2. SELF-REGULATED LEARNING STRATEGIES</p></td><td align="left"><p>Strategies associated with the monitoring of monitoring one's individual learning abilities </p></td><td align="left"><p>The attending physician utilizes a strategy to monitor how they are learning during a challenging new procedure </p></td><td align="left"><p>C.2.1. Orientation</p></td><td align="left"><p>SRL strategies associated with the establishment of given knowledge and establishing plans</p></td><td align="left"><p>As a physician begins examining a patient, the use strategies to orient themselves and collect information about their status and wellbeing </p></td><td align="left"><p>C.2.1.a. Hypothesizing</p></td><td align="left"><p>Developing a hypothesis for a problem</p></td><td align="left"><p>The senior actively develops a hypothesis over the patient's condition</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>C.2.1.b. Identifying/repeating important information</p></td><td align="left"><p>identifying important information to help solve a problem</p></td><td align="left"><p>The junior medical trainee identifies that the patient has a pre-existing condition</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>C.2.1.c. Identifying task demands</p></td><td align="left"><p>Identifying the demands or criteria of a task that is presented</p></td><td align="left"><p>The medical trainee identifies that to intubate a patient, they must first apply an anaesthetic</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>C.2.1.d. Activating prior knowledge</p></td><td align="left"><p>Recalling relevant prior information</p></td><td align="left"><p>The medical trainee remembers a critical part of a task that they were taught in a prior lab</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>C.2.1.e. Establishing givens in a task</p></td><td align="left"><p>Establishing the requisite givens in a task before starting planning</p></td><td align="left"><p>The senior medical trainee ask for all team members to give they every piece of information possible before deliberating on a prognosis</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>C.2.2. Planning</p></td><td align="left"><p>SRL strategies associated with effective planning of goals and sub-goals</p></td><td align="left"><p>In order to effectively deliver care, a physician chooses to go about establishing goals and sub-goals for what success will look like</p></td><td align="left"><p>C.2.2.a. Selecting appropriate strategy</p></td><td align="left"><p>Selecting the most appropriate strategy to solve a problem given the information available</p></td><td align="left"><p>The medical trainees select the most appropriate treatment for the patient given their condition and information gained in the initial assessment</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>C.2.2.b. Ruling out alternatives</p></td><td align="left"><p>Ruling out information that may not be useful to solve a problem</p></td><td align="left"><p>After considering all the available information, the team agrees that</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>C.2.2.c. Forming a plan</p></td><td align="left"><p>Forming a plan or setting a goal(s) to solve a problem</p></td><td align="left"><p>Senior medical trainee forms a plan on how to help the patient</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>C.2.2.d. Simplifying a problem that is presented</p></td><td align="left"><p>Simplifying or reducing a problem to its simplest form to make better sense of it</p></td><td align="left"><p>The junior medical trainee determines that the team can reduce patient treatment time by administering 3 drugs at the same time, with no side-effects to the patient</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>C.2.2.e. Looking for specific information</p></td><td align="left"><p>Identifying specific information when forming a plan</p></td><td align="left"><p>When examining a patient, the medical trainee is looking for the ABCs of the patient which will give them specific information on the patient's vital signs</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>C.2.2.f. Allocating tasks or roles to individuals or the team</p></td><td align="left"><p>Delegating work or specific tasks to team members to ensure that work is completed</p></td><td align="left"><p>The senior medical trainee assigns separate roles to the junior, nurse and RT to complete to help the patient as soon as possible</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>C.2.2.g. Setting a subgoal</p></td><td align="left"><p>Setting a sub-goal to accomplish a task</p></td><td align="left"><p>In order to complete a larger task, the team sets a sub-goal to evaluate their completion of a broader task</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>C.2.3. Execution</p></td><td align="left"><p>SRL strategies associated with effectively executing goals and sub-goals</p></td><td align="left"><p>As the physician establishes goals, they engage in strategies to ensures that they are</p><p>effectively meeting those goals</p></td><td align="left"><p>C.2.3.a. Commenting on explanation</p></td><td align="left"><p>An individual provides a comment to an explanation</p></td><td align="left"><p>The junior medical trainee proves a follow-up response to an explanation about a procedure</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>C.2.3.b. Reacting to a questioner</p></td><td align="left"><p>An individual reacts to a questioner in an active manner</p></td><td align="left"><p>When a medical trainee does not understand how to complete a procedure, they ask a nurse who has more experience in completing this task</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>C.2.3.c. Estimating</p></td><td align="left"><p>An individual uses estimation to provide an informed response</p></td><td align="left"><p>The senior medical trainee estimates that they have approximately 5 min before a Code Blue must be called</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>C.2.3.d. Giving Up</p></td><td align="left"><p>An individual gives up completing their task</p></td><td align="left"><p>The medical trainees give up on a task because it is too difficult to complete; the patient dies</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>C.2.3.e. Executing a plan or a procedure</p></td><td align="left"><p>An individual executes a plan or procedure that is given to them</p></td><td align="left"><p>The junior medical trainee is told to complete a procedure and executes it as directed</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>C.2.4. Executive monitoring</p></td><td align="left"><p>SRL strategies associated with the effective monitoring of an individuals executive controls</p><p>while learning</p></td><td align="left"><p>While engaged in a complex task, a physician wants to be able to know if and how well they</p><p>are doing while executing their task. They need to objectively monitor how they are</p><p>doing to chart their improvement</p></td><td align="left"><p>C.2.4.a. Self questioning to form goals</p></td><td align="left"><p>An individual questions their own understanding as they for a goal or sub-goal</p></td><td align="left"><p>The medical trainee openly states, "Do I remember how to complete a procedure?"</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>C.2.4.b. Claiming progress in understanding</p></td><td align="left"><p>An individual vocalizes their growth in understanding</p></td><td align="left"><p>"Fantastic, we are doing a better job at stabilizing the patient."</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>C.2.4.c. Checking for self-understanding</p></td><td align="left"><p>An individual actively checks their own understanding of a question</p></td><td align="left"><p>"Okay, so just to clarify: how many milligrams of epi should I administer?"</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>C.2.4.d. Soliciting or providing feedback</p></td><td align="left"><p>Providing feedback to a team member</p></td><td align="left"><p>The senior medical trainee tell the junior, "you are doing really well with this task, keep up the good work."</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>C.2.4.e. Noticing inconsistencies, confusion</p></td><td align="left"><p>Identifying confusion or a lack of understanding in one's knowledge</p></td><td align="left"><p>"I'm confused with direction on this task. Can you clarify what you are asking?"</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>C.2.4.f. Noticing unfamiliar ideas or gaps in knowledge</p></td><td align="left"><p>Noticing a gap in knowledge</p></td><td align="left"><p>"Wait a minute, I don't think we know how to complete this procedure."</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>C.2.5. Evaluation</p></td><td align="left"><p>SRL strategies associated with effectively evaluating performance</p></td><td align="left"><p>After completing their primary task, a physician wants to evaluate how they performed</p></td><td align="left"><p>C.2.5.a. Help seeking</p></td><td align="left"><p>Seeking help to evaluate one's learning</p></td><td align="left"><p>A junior resident asks their senior how to complete a difficult task because they have only completed this task in a lab</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>C.2.5.b. Evaluating strategy</p></td><td align="left"><p>Evaluating the effectiveness of a learning strategy that one has used</p></td><td align="left"><p>The team checks the effectiveness of their work by running a test</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>C.2.5.c. Verifying the outcome of a task/event</p></td><td align="left"><p>Verifying the success of a task that one has executed</p></td><td align="left"><p>Once a medical trainee completes a task, they review what they have done to make sure that it is the best work they could do</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>C.2.5.d. Self-criticism</p></td><td align="left"><p>Engaging in self-criticism for the purpose of development</p></td><td align="left"><p>A medical trainee openly makes a statement being critical of their performance</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>C.2.5.e. Summarising or using analogues after a task</p></td><td align="left"><p>Summarising what the individual has learned or done during the course of a task</p></td><td align="left"><p>When asking the team about how to complete a procedure, the senior medical trainee makes an analogy to describe how to complete it</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>C.2.6. Elaboration</p></td><td align="left"><p>SRL strategies associated with the continuation of ideas</p></td><td align="left"><p>After completing a scenario, the lead physician discusses things that the team may want</p><p>to consider next time</p></td><td align="left"><p>C.2.6.a. Justifying</p></td><td align="left"><p>An individual justifies the response they have given to themselves or the team</p></td><td align="left"><p>The senior medical trainee justifies their course of treatment to the team</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>C.2.6.b. Inferring</p></td><td align="left"><p>An inference is made about an idea that was discussed</p></td><td align="left"><p>The medical trainee makes an inference off of the patient's condition</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>C.2.6.c. Paraphrase or summarize</p></td><td align="left"><p>An individual summarizes or paraphrases an idea that they had just discussed</p></td><td align="left"><p>The senior medical trainee periodically summarizes the patient's current status to the team</p></td></tr><tr><td align="left" /><td align="left" /><td align="left"><p>C.3. SOCIALLY SHARED REGULATION STRATEGIES</p></td><td align="left"><p>Regulation strategies associated with team-level regulation and decision making</p></td><td align="left"><p>As the team is faced with a challenging patient they</p><p>choose a strategy to make sure that they are all </p></td><td align="left"><p>C.3.1. Facilitation</p></td><td align="left"><p>Social interactions that encourage the facilitation of team interactions</p></td><td align="left"><p>As the situation develops, the lead physician makes a suggestion for a new direction that</p><p>that the team may take given a prognosis</p></td><td align="left"><p>C.3.1.a. Activating the team with a new construct or idea in line with previous direction/action taken</p></td><td align="left"><p>The team becomes activated with a new idea or direction that is shared between them, based on a previous direction they had taken</p></td><td align="left"><p>When deliberating about the course of treatment, a medical trainee suggests something that a teacher had told them in their last lab</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>effectively</p><p>engaging with their tasks</p></td><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>C.3.1.b. Confirm that the previous direction was correct</p></td><td align="left"><p>The team comes together and confirms that the previous direction or course of action they took was correct</p></td><td align="left"><p>When making decisions, the team comes together to confirm that their recent treatment was effective</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>C.3.2. Inhibition</p></td><td align="left"><p>Social actions that inhibit or discourage pro-social interactions between team members</p></td><td align="left"><p>As the team works together, they start to exhibit qualities and intercations that appear to</p><p>restrict or compromise the actions of the team</p></td><td align="left"><p>C.3.2.a. Slowing down the continuation from the previous direction</p></td><td align="left"><p>The team slows down their response to a situation to move-on from it</p></td><td align="left"><p>As the patient's condition improves, the team slows down and reassesses their treatment as the patient's conditions becomes less dire</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>C.3.2.b. Speeding up the continuation from the previous direction</p></td><td align="left"><p>The team speeds up their response to a situation to move-on from it</p></td><td align="left"><p>As the patient's condition deteriorates, the team accelerates their course of treatment to save the patient</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>C.3.2.c. Changing the direction of a previous activity or task</p></td><td align="left"><p>The team changes its response or direction to a task based on previous information</p></td><td align="left"><p>After getting test results back, the residnets change their course of treatment based on that information</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>C.3.2.d. Unmotivated team members</p></td><td align="left"><p>Team members do not display motivation to engage or complete their work</p></td><td align="left"><p>A team member actively disengages when asked to complete a task; the medical trainee does not complete an assigned task out of their free will</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>C.3.2.e. Unequal participation or distribution of work</p></td><td align="left"><p>Team member do not equally participate in the work provided</p></td><td align="left"><p>One team member visibly does more work than others; or there is an imbalance in assigned work tasks that a medical trainee is asked to complete</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>C.3.3. Affective Social Presence (ASP)</p></td><td align="left"><p>Social interactions that encourage positive emotional expressions to the team</p></td><td align="left"><p>When addressing member of a team, the leader uses language that helps to create a positive</p><p>emotional state amongst all the members of the team</p></td><td align="left"><p>C.3.3.a. Expressions conveying emotions/Interpersonal sensitivity</p></td><td align="left"><p>A team member praises another or provides a positive emotional expression of support or affirmation</p></td><td align="left"><p>"I was very stressed about completing this task, but I'm glad that I could rely on your support!"</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>C.3.3.b. Showing respect and honour to others/Mutual respect</p></td><td align="left"><p>A team member demonstrates respect by greeting members of their team, and professionalism when interacting</p></td><td align="left"><p>When working with others, every member of the team provides professional courtesy to all those around them</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>C.3.3.c. Polite disagreement</p></td><td align="left"><p>Expressing polite disagreement between team members</p></td><td align="left"><p>The junior medical trainees disagrees with the prognosis of the patient that the senior has provided, but they are calm and non-combative with expressing their disagreement</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>C.3.3.d. Using humour</p></td><td align="left"><p>Telling a joke or providing some humorous levity to the team</p></td><td align="left"><p>A medical trainee tells a small joke to help a levity to a difficult situation</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>C.3.4. Interactive Social Presence (ISP)</p></td><td align="left"><p>Social actions that promote team interaction</p></td><td align="left"><p>Members of a team use language that builds a team and helps to foster stronger connectionsbetween all of the members</p></td><td align="left"><p>C.3.4.a. Complimenting</p></td><td align="left"><p>Complementing a team member for the work they have done or are doing</p></td><td align="left"><p>"You've done a great job with collecting x-ray results so fast"</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>C.3.4.b. Expressing gratitude</p></td><td align="left"><p>Expressing gratitude to a team member for the work they have done or are doing</p></td><td align="left"><p>"I'm thankful to have you help me with this..."</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>C.3.4.c. Encouraging contributions</p></td><td align="left"><p>Encouraging team members to actively be involved in the current task or future tasks</p></td><td align="left"><p>The senior medical trainee actively encourages participation in the team's activity by verbal and physical gesture or explicit instructions</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>C.3.4.d. Asking questions</p></td><td align="left"><p>Asking a question from one team member to the other</p></td><td align="left"><p>A medical trainee asks a question to another to enquire about how to best complete a procedure</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>C.3.4.e. Expressing agreement</p></td><td align="left"><p>Expressing agreement verbally or in gesture from one team member to another</p></td><td align="left"><p>A medical trainee provides a 'thumbs up' or verbal cue to express agreement while working on a patient</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>C.3.4.f. Giving information to a team member or the team</p></td><td align="left"><p>Team members sharing information</p></td><td align="left"><p>Team members share information freely between each other during a treatment</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>C.3.5. Cohesive Social Presence (CSP)</p></td><td align="left"><p>Social interactions that promote camaraderie and positive team interactions</p></td><td align="left"><p>Members of a team use a variety of positive interactions and language as they work together</p></td><td align="left"><p>C.3.5.a. Referring to the team using plural and inclusive pronouns; e.g. we</p></td><td align="left"><p>Using pro-social language that encourages camaraderie and individuals to focus on their role as part of a team</p></td><td align="left"><p>"We're doing great work everyone!"</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>C.3.5.b. Autocratic leadership style (top-down approach)</p></td><td align="left"><p>Leadership focuses on autocratic tendencies that disregard the opinions of others and discourage input from team members when making decisions</p></td><td align="left"><p>The senior medical trainee makes decisions on a unilateral basis with no involvement from their team</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>C.3.5.c. Democratic leadership style (bottom-up approach)</p></td><td align="left"><p>Leadership demonstrates a focus on consensus-building and involving subordinates in decision making</p></td><td align="left"><p>The senior medical trainee actively seeks to involve their junior, nurses, and RTs in determining a diagnosis</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>C.3.5.d. Phatics, salutations provided to the team</p></td><td align="left"><p>Offering positive salutation and regards to team members</p></td><td align="left"><p>"Great team keep up the solid work!"</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>C.3.6. Negative social interactions</p></td><td align="left"><p>Team interactions that are negatively-valanced</p></td><td align="left"><p>Members of the team show negative social interactions as they help a patient</p></td><td align="left"><p>C.3.6.a. Not listening actively</p></td><td align="left"><p>Team members do not engage actively when listening to team members</p></td><td align="left"><p>The senior medical trainee does not listen to their junior as they share results of an x-ray that is critical to determining the patient's condition</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>C.3.6.b. Showing distractive behaviours</p></td><td align="left"><p>Demonstrating distractive behavior while engaged within the team</p></td><td align="left"><p>The junior medical trainee keeps distracting the team by playing with their lanyard while they should be aiding the team</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>C.3.6.c. Negative criticism provided</p></td><td align="left"><p>Negative criticism is provided that does not focus on constructive outcomes from one member to another</p></td><td align="left"><p>The senior medical trainee tells the RT that "you are stupid, why don't you find another line of work"</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>C.3.6.d. Low team cohesion</p></td><td align="left"><p>Creating an environment where team members are encouraged to think of individualises</p></td><td align="left"><p>The Code Blue team lacks team cohesions and has stopped communicating with each other</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>C.3.6.e. Discouraging participation</p></td><td align="left"><p>Actively discouraging a team member(s) to participate through verbal of physical cues</p></td><td align="left"><p>When the junior medical trainee proposes a possible prognosis, the senior medical trainee dismisses their opinion and tells them to "go make yourself useful elsewhere..."</p></td></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>C.3.6.f. Unsupportive team climate</p></td><td align="left"><p>Creating an environment where team members feel uncomfortable, unfriendly, and lack trust</p></td><td align="left"><p>The chief medical trainee actively insults members of their team and uses language that belittles nurses and their junior medical trainee</p></td></tr></tbody></table> </ephtml> </p> <hd id="AN0180499035-34">Appendix 2</hd> <p>Table 7</p> <p>Table 7 Summary of Coding Observations Frequencies</p> <p> <ephtml> <table frame="hsides" rules="groups"><thead><tr><th align="left" colspan="2" /><th align="left" colspan="5"><p>B. 1 Attention Tendency</p></th><th align="left" colspan="4"><p>B.2 Vocalics</p></th><th align="left" colspan="5"><p>B.3 Bodily Expression</p></th></tr></thead><tbody><tr><td align="left"><p>Simulation</p></td><td align="left"><p>Stage of Simulation</p></td><td align="left"><p><italic>B.1.a. Gaze towards the patient</italic></p></td><td align="left"><p><italic>B.1.b. Gaze towards an information source</italic></p></td><td align="left"><p><italic>B.1.c. Gaze away</italic></p></td><td align="left"><p><italic>B.1.d. Gaze towards others</italic></p></td><td align="left"><p><italic>B.1.e. Gaze directed downward</italic></p></td><td align="left"><p><italic>B.2.1. Volume of speech</italic></p></td><td align="left"><p><italic>B.2.2. Speed of speech</italic></p></td><td align="left"><p><italic>B.2.3. Verbal filters</italic></p></td><td align="left"><p><italic>B.2.4. Pitch of speech</italic></p></td><td align="left"><p><italic>B.3.1. Facial expression</italic></p></td><td align="left"><p><italic>B.3.2. Head</italic></p></td><td align="left"><p><italic>B.3.3. Shoulders</italic></p></td><td align="left"><p><italic>B.3.4. Hands</italic></p></td><td align="left"><p><italic>B.3.5. Standing posture</italic></p></td></tr><tr><td align="left"><p>V1</p></td><td align="left" rowspan="3"><p>Beginning</p><p>Escalation</p><p>Peak</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>2/0.06</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>2/0.06</p></td><td align="left"><p>2/0.06</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>1/0.03</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>2/0.06</p></td></tr><tr><td align="left" /><td align="left"><p>0/0.00</p></td><td align="left"><p>1/0.03</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>1/0.03</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>2/0.06</p></td><td align="left"><p>2/0.06</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>1/0.03</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>2/0.06</p></td></tr><tr><td align="left" /><td align="left"><p>2/0.06</p></td><td align="left"><p>2/0.06</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>2/0.06</p></td><td align="left"><p>2/0.06</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>1/0.03</p></td><td align="left"><p>2/0.06</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>2/0.06</p></td><td align="left"><p>2/0.06</p></td></tr><tr><td align="left"><p>V2</p></td><td align="left" rowspan="3"><p>Beginning</p><p>Escalation</p><p>Peak</p></td><td align="left"><p>6/0.08</p></td><td align="left"><p>6/0.08</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>2/0.03</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>6/0.08</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>6/0.08</p></td><td align="left"><p>4/0.05</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>6/0.08</p></td><td align="left"><p>6/0.08</p></td></tr><tr><td align="left" /><td align="left"><p>2/0.03</p></td><td align="left"><p>1/0.01</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>2/0.03</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>2/0.03</p></td><td align="left"><p>2/0.03</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>1/0.01</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>4/0.05</p></td><td align="left"><p>1/0.01</p></td></tr><tr><td align="left" /><td align="left"><p>2/0.03</p></td><td align="left"><p>2/0.03</p></td><td align="left"><p>1/0.01</p></td><td align="left"><p>1/0.01</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>3/0.04</p></td><td align="left"><p>3/0.04</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>2/0.03</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>4/0.05</p></td><td align="left"><p>0/0.00</p></td></tr><tr><td align="left"><p>V3</p></td><td align="left" rowspan="3"><p>Beginning</p><p>Escalation</p><p>Peak</p></td><td align="left"><p>2/0.04</p></td><td align="left"><p>1/0.02</p></td><td align="left"><p>2/0.04</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>2/0.04</p></td><td align="left"><p>2/0.04</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>1/0.02</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>1/0.02</p></td><td align="left"><p>5/0.11</p></td></tr><tr><td align="left" /><td align="left"><p>3/0.07</p></td><td align="left"><p>2/0.04</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>5/0.11</p></td><td align="left"><p>3/0.07</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>1/0.02</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>1/0.02</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>1/0.02</p></td></tr><tr><td align="left" /><td align="left"><p>2/0.04</p></td><td align="left"><p>2/0.04</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>1/0.02</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>2/0.04</p></td><td align="left"><p>1/0.02</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>1/0.02</p></td><td align="left"><p>2/0.04</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>2/0.04</p></td></tr><tr><td align="left"><p>V4</p></td><td align="left" rowspan="3"><p>Beginning</p><p>Escalation</p><p>Peak</p></td><td align="left"><p>2/0.02</p></td><td align="left"><p>1/0.01</p></td><td align="left"><p>2/0.02</p></td><td align="left"><p>3/0.03</p></td><td align="left"><p>2/0.02</p></td><td align="left"><p>3/0.03</p></td><td align="left"><p>2/0.02</p></td><td align="left"><p>1/0.01</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>5/0.05</p></td><td align="left"><p>0</p></td><td align="left"><p>1/0.01</p></td><td align="left"><p>3/0.03</p></td><td align="left"><p>4/0.04</p></td></tr><tr><td align="left" /><td align="left"><p>3/0.03</p></td><td align="left"><p>2/0.02</p></td><td align="left"><p>1/0.01</p></td><td align="left"><p>2/0.02</p></td><td align="left"><p>2/0.02</p></td><td align="left"><p>3/0.03</p></td><td align="left"><p>3/0.03</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>1/0.01</p></td><td align="left"><p>2/0.02</p></td><td align="left"><p>1/0.01</p></td><td align="left"><p>2/0.02</p></td><td align="left"><p>5/0.05</p></td></tr><tr><td align="left" /><td align="left"><p>4/0.04</p></td><td align="left"><p>4/0.04</p></td><td align="left"><p>3/0.03</p></td><td align="left"><p>5/0.05</p></td><td align="left"><p>2/0.02</p></td><td align="left"><p>6/0.06</p></td><td align="left"><p>6/0.06</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>2/0.02</p></td><td align="left"><p>4/0.04</p></td><td align="left"><p>1/0.01</p></td><td align="left"><p>1/0.01</p></td><td align="left"><p>8/0.08</p></td></tr><tr><td align="left"><p>V5</p></td><td align="left" rowspan="3"><p>Beginning</p><p>Escalation</p><p>Peak</p></td><td align="left"><p>1/0.01</p></td><td align="left"><p>1/0.01</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>1/0.01</p></td><td align="left"><p>1/0.01</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td></tr><tr><td align="left" /><td align="left"><p>2/0.02</p></td><td align="left"><p>2/0.02</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>2/0.02</p></td><td align="left"><p>2/0.02</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>2/0.02</p></td><td align="left"><p>2/0.02</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>2/0.02</p></td><td align="left"><p>2/0.02</p></td></tr><tr><td align="left" /><td align="left"><p>6/0.05</p></td><td align="left"><p>12/0.11</p></td><td align="left"><p>5/0.04</p></td><td align="left"><p>12/0.11</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>18/0.16</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>1/0.01</p></td><td align="left"><p>18/0.16</p></td><td align="left"><p>11/0.10</p></td><td align="left"><p>17/0.15</p></td><td align="left"><p>17/0.15</p></td><td align="left"><p>2/0.02</p></td><td align="left"><p>2/0.02</p></td></tr><tr><td align="left"><p>V6</p></td><td align="left" rowspan="3"><p>Beginning</p><p>Escalation</p><p>Peak</p></td><td align="left"><p>3/0.02</p></td><td align="left"><p>6/0.03</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>4/0.02</p></td><td align="left"><p>2/0.01</p></td><td align="left"><p>8/0.04</p></td><td align="left"><p>5/0.03</p></td><td align="left"><p>4/0.02</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>6/0.03</p></td><td align="left"><p>9/0.05</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>3/0.02</p></td><td align="left"><p>1/0.01</p></td></tr><tr><td align="left" /><td align="left"><p>4/0.02</p></td><td align="left"><p>12/0.06</p></td><td align="left"><p>1/0.01</p></td><td align="left"><p>12/0.06</p></td><td align="left"><p>2/0.01</p></td><td align="left"><p>17/0.09</p></td><td align="left"><p>17/0.09</p></td><td align="left"><p>21/0.11</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>13/0.07</p></td><td align="left"><p>1/0.01</p></td><td align="left"><p>1/0.01</p></td><td align="left"><p>5/0.03</p></td><td align="left"><p>2/0.01</p></td></tr><tr><td align="left" /><td align="left"><p>2/0.01</p></td><td align="left"><p>4/0.02</p></td><td align="left"><p>1/0.01</p></td><td align="left"><p>4/0.02</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>7/0.04</p></td><td align="left"><p>2/0.01</p></td><td align="left"><p>2/0.01</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>5/0.03</p></td><td align="left"><p>4/0.02</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>4/0.02</p></td><td align="left"><p>0/0.00</p></td></tr><tr><td align="left"><p>V7</p></td><td align="left" rowspan="3"><p>Beginning</p><p>Escalation</p><p>Peak</p></td><td align="left"><p>1/0.01</p></td><td align="left"><p>5/0.03</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>2/0.01</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>6/0.04</p></td><td align="left"><p>4/0.03</p></td><td align="left"><p>1/0.01</p></td><td align="left"><p>1/0.01</p></td><td align="left"><p>2/0.01</p></td><td align="left"><p>3/0.03</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>7/0.05</p></td><td align="left"><p>0/0.00</p></td></tr><tr><td align="left" /><td align="left"><p>7/0.05</p></td><td align="left"><p>12/0.08</p></td><td align="left"><p>1/0.01</p></td><td align="left"><p>4/0.03</p></td><td align="left"><p>1/0.01</p></td><td align="left"><p>11/0.07</p></td><td align="left"><p>10/0.07</p></td><td align="left"><p>5/0.03</p></td><td align="left"><p>1/0.01</p></td><td align="left"><p>1/0.01</p></td><td align="left"><p>5/0.03</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>8/0.05</p></td><td align="left"><p>0/0.00</p></td></tr><tr><td align="left" /><td align="left"><p>0/0.00</p></td><td align="left"><p>7/0.05</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>6/0.04</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>7/0.05</p></td><td align="left"><p>6/0.04</p></td><td align="left"><p>5/0.03</p></td><td align="left"><p>1/0.01</p></td><td align="left"><p>3/0.03</p></td><td align="left"><p>3/0.03</p></td><td align="left"><p>3/0.03</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>9/0.06</p></td></tr><tr><td align="left"><p>V8</p></td><td align="left" rowspan="3"><p>Beginning</p><p>Escalation</p><p>Peak</p></td><td align="left"><p>7/0.05</p></td><td align="left"><p>5/0.04</p></td><td align="left"><p>6/0.04</p></td><td align="left"><p>5/0.04</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>10/0.07</p></td><td align="left"><p>10/0.07</p></td><td align="left"><p>5/0.04</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>8/0.06</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>6/0.04</p></td><td align="left"><p>0/0.00</p></td></tr><tr><td align="left" /><td align="left"><p>6/0.04</p></td><td align="left"><p>3/0.02</p></td><td align="left"><p>2/0.01</p></td><td align="left"><p>6/0.04</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>7/0.05</p></td><td align="left"><p>7/0.05</p></td><td align="left"><p>3/0.02</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>7/0.05</p></td><td align="left"><p>7/0.05</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>7/0.05</p></td></tr><tr><td align="left" /><td align="left"><p>2/0.01</p></td><td align="left"><p>3/0.02</p></td><td align="left"><p>4/0.03</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>4/0.03</p></td><td align="left"><p>4/0.03</p></td><td align="left"><p>1/0.01</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>2/0.01</p></td><td align="left"><p>2/0.01</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>2/0.01</p></td><td align="left"><p>0/0.00</p></td></tr><tr><td align="left"><p>V9</p></td><td align="left" rowspan="3"><p>Beginning</p><p>Escalation</p><p>Peak</p></td><td align="left"><p>3/0.04</p></td><td align="left"><p>2/0.02</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>3/0.04</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>3/0.04</p></td><td align="left"><p>3/0.04</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>2/0.02</p></td><td align="left"><p>2/0.02</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>1/0.01</p></td><td align="left"><p>0/0.00</p></td></tr><tr><td align="left" /><td align="left"><p>6/0.07</p></td><td align="left"><p>7/0.09</p></td><td align="left"><p>5/0.06</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>2/0.02</p></td><td align="left"><p>7/0.09</p></td><td align="left"><p>7/0.09</p></td><td align="left"><p>1/0.01</p></td><td align="left"><p>3/0.04</p></td><td align="left"><p>5/0.06</p></td><td align="left"><p>5/0.06</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>2/0.02</p></td><td align="left"><p>2/0.02</p></td></tr><tr><td align="left" /><td align="left"><p>1/0.01</p></td><td align="left"><p>1/0.01</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>1/0.01</p></td><td align="left"><p>1/0.01</p></td><td align="left"><p>2/0.02</p></td><td align="left"><p>1/0.01</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>1/0.01</p></td><td align="left"><p>1/0.01</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>1/0.01</p></td></tr><tr><td align="left"><p>V10</p></td><td align="left" rowspan="3"><p>Beginning</p><p>Escalation</p><p>Peak</p></td><td align="left"><p>7/0.07</p></td><td align="left"><p>6/0.06</p></td><td align="left"><p>1/0.01</p></td><td align="left"><p>6/0.06</p></td><td align="left"><p>0</p></td><td align="left"><p>6/0.06</p></td><td align="left"><p>9/0.08</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>2/0.02</p></td><td align="left"><p>5/0.05</p></td><td align="left"><p>5/0.05</p></td><td align="left"><p>1/0.01</p></td><td align="left"><p>8/0.07</p></td><td align="left"><p>0/0.00</p></td></tr><tr><td align="left" /><td align="left"><p>5/0.05</p></td><td align="left"><p>4/0.04</p></td><td align="left"><p>1/0.01</p></td><td align="left"><p>5/0.05</p></td><td align="left"><p>1/0.01</p></td><td align="left"><p>5/0.05</p></td><td align="left"><p>5/0.05</p></td><td align="left"><p>1/0.01</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>5/0.05</p></td><td align="left"><p>5/0.05</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>5/0.05</p></td><td align="left"><p>1/0.01</p></td></tr><tr><td align="left" /><td align="left"><p>1/0.01</p></td><td align="left"><p>1/0.01</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>1/0.01</p></td><td align="left"><p>1/0.01</p></td><td align="left"><p>1/0.01</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>1/0.01</p></td><td align="left"><p>1/0.01</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>1/0.01</p></td></tr></tbody></table> </ephtml> </p> <p> <ephtml> <table frame="hsides" rules="groups"><thead><tr><th align="left" /><th align="left" /><th align="left" colspan="7"><p>Individual Regulation strategies</p></th><th align="left" colspan="7"><p>Socially-Shared Regulation strategies</p></th></tr></thead><tbody><tr><td align="left"><p>Simulation</p></td><td align="left"><p>Stage of Simulation</p></td><td align="left"><p><italic>C.2.1. Orientation</italic></p></td><td align="left"><p><italic>C.2.2. Planning</italic></p></td><td align="left"><p><italic>C.2.3. Execution</italic></p></td><td align="left"><p><italic>C.2.4. Executive monitoring</italic></p></td><td align="left"><p><italic>C.2.5. Evaluation</italic></p></td><td align="left"><p><italic>C.2.6. Elaboration</italic></p></td><td align="left"><p><italic>Total</italic></p></td><td align="left"><p><italic>C.3.1. Facilitation</italic></p></td><td align="left"><p><italic>C.3.2. Inhibition</italic></p></td><td align="left"><p><italic>C.3.3. Affective Social Presence (ASP)</italic></p></td><td align="left"><p><italic>C.3.4. Interactive Social Presence (ISP)</italic></p></td><td align="left"><p><italic>C.3.5. Cohesive Social Presence (CSP)</italic></p></td><td align="left"><p><italic>C.3.6. Negative social interactions</italic></p></td><td align="left"><p><italic>Total</italic></p></td></tr><tr><td align="left"><p>V1</p></td><td align="left" rowspan="3"><p>Beginning</p><p>Escalation</p><p>Peak</p></td><td align="left"><p>2/0.06</p></td><td align="left"><p>8/0.22</p></td><td align="left"><p>1/0.03</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>1/0.03</p></td><td align="left" rowspan="3"><p>36/1</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left" rowspan="3"><p>14/1</p></td></tr><tr><td align="left" /><td align="left"><p>2/0.06</p></td><td align="left"><p>4/0.11</p></td><td align="left"><p>3/0.08</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>1/0.03</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>1/0.07</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>3/0.21</p></td><td align="left"><p>1/0.07</p></td><td align="left"><p>0/0.00</p></td></tr><tr><td align="left" /><td align="left"><p>2/0.06</p></td><td align="left"><p>8/0.22</p></td><td align="left"><p>3/0.08</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>1/0.03</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>1/0.07</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>3/0.21</p></td><td align="left"><p>5/0.36</p></td><td align="left"><p>0/0.00</p></td></tr><tr><td align="left"><p>V2</p></td><td align="left" rowspan="3"><p>Beginning</p><p>Escalation</p><p>Peak</p></td><td align="left"><p>2/0.08</p></td><td align="left"><p>7/0.29</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>1/0.04</p></td><td align="left"><p>2/0.08</p></td><td align="left" rowspan="3"><p>24/1</p></td><td align="left"><p>1/0.04</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>2/0.09</p></td><td align="left"><p>2/0.09</p></td><td align="left"><p>5/0.21</p></td><td align="left"><p>0/0.00</p></td><td align="left" rowspan="3"><p>23/1</p></td></tr><tr><td align="left" /><td align="left"><p>0/0.00</p></td><td align="left"><p>2/0.08</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>3/0.13</p></td><td align="left"><p>4/0.17</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td></tr><tr><td align="left" /><td align="left"><p>4/0.17</p></td><td align="left"><p>3/0.13</p></td><td align="left"><p>2/0.08</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>1/0.04</p></td><td align="left"><p>1/0.04</p></td><td align="left"><p>1/0.04</p></td><td align="left"><p>1/0.04</p></td><td align="left"><p>2/0.09</p></td><td align="left"><p>1/0.04</p></td><td align="left"><p>0/0.00</p></td></tr><tr><td align="left"><p>V3</p></td><td align="left" rowspan="3"><p>Beginning</p><p>Escalation</p><p>Peak</p></td><td align="left"><p>1/0.07</p></td><td align="left"><p>3/0.20</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left" rowspan="3"><p>15/1</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>2/0.14</p></td><td align="left" rowspan="3"><p>14/1</p></td></tr><tr><td align="left" /><td align="left"><p>1/0.07</p></td><td align="left"><p>1/0.07</p></td><td align="left"><p>1/0.07</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>1/0.07</p></td><td align="left"><p>1/0.07</p></td><td align="left"><p>1/0.07</p></td><td align="left"><p>2/0.14</p></td></tr><tr><td align="left" /><td align="left"><p>2/0.13</p></td><td align="left"><p>2/0.13</p></td><td align="left"><p>3/0.20</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>1/0.07</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>1/0.07</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>1/0.07</p></td><td align="left"><p>4/0.29</p></td><td align="left"><p>1/0.07</p></td><td align="left"><p>0/0.00</p></td></tr><tr><td align="left"><p>V4</p></td><td align="left" rowspan="3"><p>Beginning</p><p>Escalation</p><p>Peak</p></td><td align="left"><p>2/0.04</p></td><td align="left"><p>4/0.08</p></td><td align="left"><p>1/0.02</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>1/0.02</p></td><td align="left"><p>2/0.04</p></td><td align="left" rowspan="3"><p>48/1</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>6/0.21</p></td><td align="left"><p>2/0.07</p></td><td align="left"><p>0/0.00</p></td><td align="left" rowspan="3"><p>28/1</p></td></tr><tr><td align="left" /><td align="left"><p>1/0.02</p></td><td align="left"><p>4/0.08</p></td><td align="left"><p>2/0.04</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>1/0.02</p></td><td align="left"><p>1/0.02</p></td><td align="left"><p>1/0.04</p></td><td align="left"><p>1/0.04</p></td><td align="left"><p>1/0.04</p></td><td align="left"><p>3/0.11</p></td><td align="left"><p>2/0.07</p></td><td align="left"><p>0/0.00</p></td></tr><tr><td align="left" /><td align="left"><p>5/0.10</p></td><td align="left"><p>12/0.25</p></td><td align="left"><p>7/0.15</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>2/0.04</p></td><td align="left"><p>3/0.06</p></td><td align="left"><p>3/0.11</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>1/0.04</p></td><td align="left"><p>4/0.14</p></td><td align="left"><p>3/0.11</p></td><td align="left"><p>1/0.04</p></td></tr><tr><td align="left"><p>V5</p></td><td align="left" rowspan="3"><p>Beginning</p><p>Escalation</p><p>Peak</p></td><td align="left"><p>1/0.01</p></td><td align="left"><p>1/0.01</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left" rowspan="3"><p>83/1</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>1/0.02</p></td><td align="left"><p>1/0.02</p></td><td align="left"><p>0/0.00</p></td><td align="left" rowspan="3"><p>44/1</p></td></tr><tr><td align="left" /><td align="left"><p>2/0.02</p></td><td align="left"><p>5/0.06</p></td><td align="left"><p>2/0.02</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>1/0.02</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>4/0.09</p></td><td align="left"><p>1/0.02</p></td><td align="left"><p>0/0.00</p></td></tr><tr><td align="left" /><td align="left"><p>13/0.16</p></td><td align="left"><p>24/0.29</p></td><td align="left"><p>18/0.22</p></td><td align="left"><p>1/0.01</p></td><td align="left"><p>7/0.08</p></td><td align="left"><p>9/0.11</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>1/0.02</p></td><td align="left"><p>20/0.45</p></td><td align="left"><p>15/0.34</p></td><td align="left"><p>0/0.00</p></td></tr><tr><td align="left"><p>V6</p></td><td align="left" rowspan="3"><p>Beginning</p><p>Escalation</p><p>Peak</p></td><td align="left"><p>4/0.05</p></td><td align="left"><p>3/0.04</p></td><td align="left"><p>7/0.09</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>1/0.01</p></td><td align="left" rowspan="3"><p>75/1</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>1/0.03</p></td><td align="left"><p>1/0.03</p></td><td align="left"><p>0/0.00</p></td><td align="left" rowspan="3"><p>36/1</p></td></tr><tr><td align="left" /><td align="left"><p>11/0.15</p></td><td align="left"><p>18/0.24</p></td><td align="left"><p>10/0.13</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>4/0.05</p></td><td align="left"><p>2/0.06</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>1/0.03</p></td><td align="left"><p>14/0.39</p></td><td align="left"><p>6/0.17</p></td><td align="left"><p>0/0.00</p></td></tr><tr><td align="left" /><td align="left"><p>4/0.05</p></td><td align="left"><p>3/0.04</p></td><td align="left"><p>5/0.07</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>2/0.03</p></td><td align="left"><p>3/0.04</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>4/0.11</p></td><td align="left"><p>2/0.06</p></td><td align="left"><p>0/0.00</p></td></tr><tr><td align="left"><p>V7</p></td><td align="left" rowspan="3"><p>Beginning</p><p>Escalation</p><p>Peak</p></td><td align="left"><p>4/0.04</p></td><td align="left"><p>5/0.05</p></td><td align="left"><p>2/0.02</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>1/0.01</p></td><td align="left"><p>1/0.01</p></td><td align="left" rowspan="3"><p>98/1</p></td><td align="left"><p>1/0.02</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>5/0.09</p></td><td align="left"><p>2/0.04</p></td><td align="left"><p>0/0.00</p></td><td align="left" rowspan="3"><p>54/1</p></td></tr><tr><td align="left" /><td align="left"><p>13/0.13</p></td><td align="left"><p>18/0.18</p></td><td align="left"><p>11/0.11</p></td><td align="left"><p>1/0.01</p></td><td align="left"><p>3/0.03</p></td><td align="left"><p>8/0.08</p></td><td align="left"><p>1/0.02</p></td><td align="left"><p>2/0.04</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>13/0.24</p></td><td align="left"><p>7/0.13</p></td><td align="left"><p>0/0.00</p></td></tr><tr><td align="left" /><td align="left"><p>3/0.03</p></td><td align="left"><p>11/0.11</p></td><td align="left"><p>6/0.06</p></td><td align="left"><p>2/0.02</p></td><td align="left"><p>5/0.05</p></td><td align="left"><p>4/0.04</p></td><td align="left"><p>5/0.09</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>3/0.06</p></td><td align="left"><p>10/0.19</p></td><td align="left"><p>5/0.09</p></td><td align="left"><p>0/0.00</p></td></tr><tr><td align="left"><p>V8</p></td><td align="left" rowspan="3"><p>Beginning</p><p>Escalation</p><p>Peak</p></td><td align="left"><p>10/0.07</p></td><td align="left"><p>20/0.15</p></td><td align="left"><p>8/0.06</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>2/0.01</p></td><td align="left"><p>7/0.05</p></td><td align="left" rowspan="3"><p>136/1</p></td><td align="left"><p>3/0.05</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>2/0.04</p></td><td align="left"><p>7/0.12</p></td><td align="left"><p>7/0.12</p></td><td align="left"><p>2/0.04</p></td><td align="left" rowspan="3"><p>57/1</p></td></tr><tr><td align="left" /><td align="left"><p>12/0.09</p></td><td align="left"><p>21/0.15</p></td><td align="left"><p>11/0.08</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>2/0.01</p></td><td align="left"><p>11/0.08</p></td><td align="left"><p>5/0.09</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>11/0.19</p></td><td align="left"><p>6/0.11</p></td><td align="left"><p>2/0.04</p></td><td align="left"><p>0/0.00</p></td></tr><tr><td align="left" /><td align="left"><p>4/0.03</p></td><td align="left"><p>14/0.10</p></td><td align="left"><p>7/0.05</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>4/0.03</p></td><td align="left"><p>3/0.02</p></td><td align="left"><p>3/0.05</p></td><td align="left"><p>2/0.04</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>5/0.09</p></td><td align="left"><p>2/0.04</p></td></tr><tr><td align="left"><p>V9</p></td><td align="left" rowspan="3"><p>Beginning</p><p>Escalation</p><p>Peak</p></td><td align="left"><p>3/0.04</p></td><td align="left"><p>9/0.13</p></td><td align="left"><p>4/0.06</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left" rowspan="3"><p>67/1</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>1/0.04</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>1/0.04</p></td><td align="left"><p>2/0.07</p></td><td align="left"><p>0/0.00</p></td><td align="left" rowspan="3"><p>27/1</p></td></tr><tr><td align="left" /><td align="left"><p>13/0.19</p></td><td align="left"><p>16/0.24</p></td><td align="left"><p>5/0.07</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>7/0.10</p></td><td align="left"><p>3/0.04</p></td><td align="left"><p>1/0.04</p></td><td align="left"><p>4/0.15</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>8/0.30</p></td><td align="left"><p>7/0.26</p></td><td align="left"><p>2/0.07</p></td></tr><tr><td align="left" /><td align="left"><p>1/0.01</p></td><td align="left"><p>4/0.06</p></td><td align="left"><p>1/0.01</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>1/0.01</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>1/0.04</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td></tr><tr><td align="left"><p>V10</p></td><td align="left" rowspan="3"><p>Beginning</p><p>Escalation</p><p>Peak</p></td><td align="left"><p>12/0.13</p></td><td align="left"><p>16/0.17</p></td><td align="left"><p>9/0.09</p></td><td align="left"><p>1/0.01</p></td><td align="left"><p>2/0.02</p></td><td align="left"><p>4/0.04</p></td><td align="left" rowspan="3"><p>95/1</p></td><td align="left"><p>1/0.02</p></td><td align="left"><p>5/0.09</p></td><td align="left"><p>10/0.19</p></td><td align="left"><p>8/0.15</p></td><td align="left"><p>9/0.17</p></td><td align="left"><p>0/0.00</p></td><td align="left" rowspan="3"><p>54/1</p></td></tr><tr><td align="left" /><td align="left"><p>11/0.12</p></td><td align="left"><p>15/0.16</p></td><td align="left"><p>7/0.07</p></td><td align="left"><p>3/0.03</p></td><td align="left"><p>4/0.04</p></td><td align="left"><p>6/0.06</p></td><td align="left"><p>2/0.04</p></td><td align="left"><p>5/0.09</p></td><td align="left"><p>6/0.11</p></td><td align="left"><p>5/0.09</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td></tr><tr><td align="left" /><td align="left"><p>2/0.02</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>2/0.02</p></td><td align="left"><p>1/0.01</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>0/0.00</p></td><td align="left"><p>2/0.04</p></td><td align="left"><p>1/0.02</p></td><td align="left"><p>0/0.00</p></td></tr></tbody></table> </ephtml> </p> <hd id="AN0180499035-35">Publisher's Note</hd> <p>Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.</p> <ref id="AN0180499035-36"> <title> References </title> <blist> <bibl id="bib1" idref="ref83" type="bt">1</bibl> <bibtext> Albert M, 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  Label: Title
  Group: Ti
  Data: Analyzing Multimodal Data to Understand Medical Trainees' Regulation Strategies and Physiological Responses in High- Fidelity Medical Simulation Scenarios
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  Label: Language
  Group: Lang
  Data: English
– Name: Author
  Label: Authors
  Group: Au
  Data: <searchLink fieldCode="AR" term="%22Matthew+Moreno%22">Matthew Moreno</searchLink> (ORCID <externalLink term="http://orcid.org/0000-0002-7155-8103">0000-0002-7155-8103</externalLink>)<br /><searchLink fieldCode="AR" term="%22Lucia+Patino+Melo%22">Lucia Patino Melo</searchLink><br /><searchLink fieldCode="AR" term="%22Keerat+Grewal%22">Keerat Grewal</searchLink> (ORCID <externalLink term="http://orcid.org/0000-0002-0130-6015">0000-0002-0130-6015</externalLink>)<br /><searchLink fieldCode="AR" term="%22Negar+Matin%22">Negar Matin</searchLink><br /><searchLink fieldCode="AR" term="%22Sayed+Azher%22">Sayed Azher</searchLink> (ORCID <externalLink term="http://orcid.org/0000-0001-8840-1981">0000-0001-8840-1981</externalLink>)<br /><searchLink fieldCode="AR" term="%22Jason+M%2E+Harley%22">Jason M. Harley</searchLink> (ORCID <externalLink term="http://orcid.org/0000-0002-2061-9519">0000-0002-2061-9519</externalLink>)
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  Label: Source
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  Data: <searchLink fieldCode="SO" term="%22Metacognition+and+Learning%22"><i>Metacognition and Learning</i></searchLink>. 2024 19(3):1161-1213.
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  Data: Springer. Available from: Springer Nature. One New York Plaza, Suite 4600, New York, NY 10004. Tel: 800-777-4643; Tel: 212-460-1500; Fax: 212-460-1700; e-mail: customerservice@springernature.com; Web site: https://link.springer.com/
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  Data: Y
– Name: Pages
  Label: Page Count
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  Data: 53
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  Label: Publication Date
  Group: Date
  Data: 2024
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  Data: Journal Articles<br />Reports - Research
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  Label: Education Level
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  Data: <searchLink fieldCode="EL" term="%22Higher+Education%22">Higher Education</searchLink><br /><searchLink fieldCode="EL" term="%22Postsecondary+Education%22">Postsecondary Education</searchLink>
– Name: Subject
  Label: Descriptors
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Data+Analysis%22">Data Analysis</searchLink><br /><searchLink fieldCode="DE" term="%22Medical+Students%22">Medical Students</searchLink><br /><searchLink fieldCode="DE" term="%22Trainees%22">Trainees</searchLink><br /><searchLink fieldCode="DE" term="%22Self+Control%22">Self Control</searchLink><br /><searchLink fieldCode="DE" term="%22Responses%22">Responses</searchLink><br /><searchLink fieldCode="DE" term="%22Simulation%22">Simulation</searchLink><br /><searchLink fieldCode="DE" term="%22Fidelity%22">Fidelity</searchLink><br /><searchLink fieldCode="DE" term="%22Skill+Development%22">Skill Development</searchLink><br /><searchLink fieldCode="DE" term="%22Teamwork%22">Teamwork</searchLink><br /><searchLink fieldCode="DE" term="%22Psychophysiology%22">Psychophysiology</searchLink><br /><searchLink fieldCode="DE" term="%22Simulated+Environment%22">Simulated Environment</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1007/s11409-024-09403-z
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 1556-1623<br />1556-1631
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: Medical simulations allow trainees to work within teams to develop their self-regulated learning (SRL) and socially-shared regulated learning (SSRL) skills (Bransen et al., 2022). Both skillsets help to better prepare medical trainees for the multifaceted challenges inherent in clinical practice. SRL skills are imperative in empowering learners to optimize their performance and become autonomous guiders of their own learning (Jarvela & Hadwin, 2013), while SSRL skills are needed to ensure that teams can work collectively to regulate their behaviors and to regulate their own learning to make decisions (Hadwin & Oshige, 2011). Questions remain about not only how medical trainees' behaviors, regulation strategies, and physiological responses vary while they participate in a high-fidelity medical simulation, but how additional data channels to measure human response can provide indicators of teams' regulation strategies. Using a mixed-methods convergence design incorporating multimodal data (Azevedo & Gaševic, 2019), including behavioral, SRL and SSRL codes, and electrodermal activity, researchers studied twenty-nine (N = 29) 1st to 3rd year medical residents as they engaged in high-fidelity simulation scenarios. Results suggest that the mean-level of psychophysiological activation increase as simulations progress, in conjunction with an increase in team-regulated learning strategies to manage the effective provision of patient care from initial contact through to the delivery of critical procedures. These results provide valuable insights into the advancement of a team regulation-based framework within a high-fidelity medical simulation environment, leveraging multimodal data to reach an understanding of medical trainees' adoption of team-based approaches to team-regulation during simulation scenarios.
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  Data: As Provided
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  Label: Entry Date
  Group: Date
  Data: 2024
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  Label: Accession Number
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  Data: EJ1445647
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ1445647
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        Value: 10.1007/s11409-024-09403-z
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      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 53
        StartPage: 1161
    Subjects:
      – SubjectFull: Data Analysis
        Type: general
      – SubjectFull: Medical Students
        Type: general
      – SubjectFull: Trainees
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      – SubjectFull: Self Control
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      – TitleFull: Analyzing Multimodal Data to Understand Medical Trainees' Regulation Strategies and Physiological Responses in High- Fidelity Medical Simulation Scenarios
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