Gersten Jonker

78   Chapter 4 and student identities; this shift can be seen as an indication that the simulations were at the ZPD’s frontier, with participants moving back and forth over the border between their current level and the next developmental level. Study participants indicated that their stress was caused by their uncertainty about medical management, the deterioration of the simulation patient, and disappointment about their performance. The discomfort of an undesirable outcome in dramatic cases in which “things go wrong” has recently been identified as a key feature of powerful simulation experiences [19]. Without appropriate facilitation, this disruption could be damaging, but debriefing and feedbackmay turn the simulation into a powerful learning experience [19]. In other words, a challenging task can induce the development of new skills if the teacher provides tailored direction, creating constructive friction. Without direction, destructive friction may occur, decreasing learning [3]. The students’stressmanifested in feelings of bewilderment and disturbance of cognitive processes. The detrimental effect of stress on cognitive function during simulation is due to a reduction in “tranquility,” leading to agitation, combined with positive feelings of “invigoration” [13]. These reactions are associated with an increase in task-irrelevant, extraneous cognitive load and thus reduce working memory space for learning [13, 32]. Extraneous load caused by invigoration may include self-evaluating thoughts on performance [13] and indeed some participants feel exposed during simulation [33]. Students in our study worried about their performance and the impression they made on faculty, especially when they felt they were performing poorly. Disappointment made them aware of being observed and assessed. In our study, students engaged in the management of critically ill simulation patients who deteriorated despite the students’ best efforts, with some cases ending during cardiac arrest, as case duration was limited due to time constraints. Whether patient death in a simulation affects cognitive load, stress, or learning outcomes remains controversial [11, 14, 34–36]. Cases that are beyond the learner’s control may lead to the learner’s disengagement and impair his or her ability to handle the situation [37]. Of interest, participants in our study experienced a sense of control that brought them relief in the case of cardiac arrest. So, although the patient was moribund, the situation provided solid ground for protocolled action (i.e. students suddenly knew what to do); we suggest calling such a situation “the paradox of cardiac arrest” in simulation. This finding also indicates the