Gersten Jonker

176   Chapter 9 Second, the ACTY augmented motivation. The interaction with congenial peers in a learning community, personal formative feedback on the pre-test, and mentor support boosted motivation (Chapters 3 and 4). The three basic psychological needs to be satisfied for intrinsic motivation, according to Self-determination theory [18], further explained in Chapter 3, are the needs for relatedness, competence, and autonomy. The supportive learning environment seems to satisfy the need for relatedness, and partly the needs for competence and autonomy, stimulating students’motivation and natural tendency to develop (Chapter 3). The importance of a supportive learning environment was underlined by the way accommodating factors relieved stress in the postgraduate- level simulation pre-test of performance in managing critically-ill patients, bending it into a motivating educational experience (Chapter 4). From the perceived merit of debriefing and the identification of personal assets and deficits, as expressed in the interviews, we infer a learning goal-orientation in the participants, meaning that they are inclined to learn from mistakes at the edge of their capability [19-21]. As elaborated in chapter 4, this echoes Vygotsky’s theory of the zone of proximal development, which states that growth toward the next level requires teacher support [22, 23]. Leaving the comfort zone and engaging in guided completion of a task generates constructive friction between teaching and learning [24, 25]. Psychological safety is indispensable to make students “embrace being uncomfortable” in simulations [26, 27]. With the accommodating prerequisites, challenging simulations at the far edge of the zone of proximal development are safe and motivate students to develop their competence (Chapter 4). This major finding diverges from current recommendations to tailor simulation tasks difficulty closer to a learner’s level of development [28]. The third way the ACTY supported competence development was constituted by three subinternships with acute care learning objectives. Graduates generally rate subinternships as highly valuable [29], improving their perceived preparedness to perform tasks of a doctor, although reports on readiness to deal with emergencies are conflicting [30-32]. UK students reported having had only one to two hands-on acute care experiences in their final year student-assistantships (subinternships) [33, 34]. Although the studies in this thesis do not detail actual numbers of participations in acute situations, ACTY students and graduates experienced limited active opportunity for competence development in acute clinical care (Chapter 3). They encountered insufficient adoption into a community of practice at workplaces with limited affordances for participation [35, 36]. An explanation for limited hands-on acute care experience lies in the imperfect implementation of the ACTY. Not only the departments involved in the design, but many departments in various hospitals hosted ACTY students, often simultaneously