Dietetic Students’ Perceived Anxiety towards Simulation Activities: A Mixed-methods Pilot Study

Students completed an online questionnaire using SurveyMonkey (Momentive Inc., San Mateo, California, USA) at baseline (T1) and after the four simulations (T3). The questionnaires included questions on demographic variables as well as the French version of the State-Trait Anxiety Inventory (STAI) [22]. The STAI is a psychometric test developed by Spielberger (1983) that is widely used in different populations and is a gold standard to evaluate trait and state anxiety [2]. Trait anxiety refers to a relatively enduring and stable personality trait that predisposes individuals to experience anxiety consistently across various situations and throughout their lives [2,3]. On the other hand, state anxiety refers to the transient and situational experience of anxiety that is directly related to a specific circumstance, event, or stressor [2,3]. Both trait and state anxiety contribute to an individual’s overall experience of anxiety, with trait anxiety representing an individual’s baseline level of anxiety predisposition and state anxiety representing the fluctuating levels of anxiety experienced in response to specific circumstances [2,3]. The STAI consists of 40 self-report items answered on a 4-point Likert scale. To assess trait anxiety, questions such as “How do you generally feel?” were asked with the response options “Not at all” to “Very much so,” while questions like “How do you feel at this moment regarding …” with the response options “Almost never” to “Almost always” were asked to assess state anxiety [2]. Total scores were calculated for both state and trait anxiety by summing the answers of associated items. Lower scores on the STAI indicate lower perceived anxiety, with scores <36 being classified as very low, scores between 36 and 45 being classified as low, scores between 46 and 55 being scored as average, scores between 56 and 65 being classified as high, and scores >65 being classified as very high [23]. The fidelity and validity of the French version of the STAI were similar to the original English version [22].

Data are reported as medians and interquartile ranges. Wilcoxon signed-ranked test was used to compare pre- and post-simulation medians of trait and state anxiety. Spearman’s correlations were used to assess the association between prior experiences (i.e., in simulation or interacting with patients in clinical settings) and anxiety. All statistical analyses were performed with IBM SPSS Statistics version 24 (International Business Machines Corporation, Armonk, New York, USA. 2018), with P ≤ 0.05 considered significant.

The principal investigator of this study (IG) was the professor of the Nutrition Assessment course. IG was not involved with data collection and was not present when the simulations took place. At the time of the study, MR was a graduate student conducting a Master’s degree in Education. MR was responsible for data collection and analysis. MR had no conflict of interest with the participants enrolled in the study and was not involved with the Nutrition Assessment course development, delivery, or evaluation. AB was a doctoral-level research assistant that helped with data analysis and had no contact with students.

Each student participated in three semi-structured individual interviews (see Supplementary file 2) and one focus group (see Supplementary file 3). Individual interviews were conducted at three times points, namely at baseline (T1), after two simulations (T2), and after four simulations (T3), while the focus group was conducted at the beginning of the next semester, after the four simulations (T4). Individual interviews and focus group guides were informed by previous studies on factors that can influence anxiety [2]. These guides contained questions on feelings before and after the simulations, leading participants to discuss anxiety. Individual interviews also directly addressed sources of anxiety. MR conducted all individual interviews. MR and AB conducted the focus group discussion. Following Bloom’s (2001) recommendations, one researcher took notes while the other asked questions [24]. To encourage discussion between participants, questions were one-dimensional, open-ended, and concise [25].

To facilitate thematic analysis, individual interviews and the focus group discussion were audio-recorded and transcribed verbatim by MR and subsequently verified for clarity and accuracy by AB. MR and AB independently performed thematic analysis using NVivo QSR software (QSR International Pty Ltd. Burlington, Massachusetts, USA. Version 11, 2015). Based on previous research by Spielberger [2], themes were divided into two categories, namely individual factors and external factors that could influence anxiety. There were two pre-established individual factors, specifically stress and self-confidence, and two pre-established external factors, observers and unknown situations. The process of deciding on these pre-established themes was based on a discussion and consensus between the three researchers. Themes were also inductively derived from data. Krippendorff’s coefficient was calculated to assess inter-rater reliability [26]. MR and AB met to discuss emerging themes and possible discrepancies. IG was available to settle any disagreements.

Pre-simulations, all students perceived the experience as stressful but beneficial for their knowledge. Post-simulations, some students reported that the simulations were more stressful than initially thought, while others reported that their stress levels decreased. Pre-simulations, students had low self-confidence levels but thought these would increase with practice. Students with prior experience interacting with patients in clinical settings reported higher levels of perceived self-confidence than students with no prior experience. Post-simulations, students reported that their levels of self-confidence increased and that each simulation became easier, even when the difficulty level of the scenario increased. One student said, “If I look back at the first interview and then now, the simulations have greatly influenced my confidence. I feel more comfortable.” Another student said, “It gives me confidence that I can be a dietitian.”

Pre-simulations, a common source of anxiety was the anticipation of the unknown situation, as it was the first time that students were participating in such an educational activity as part of their curriculum. Students reported being anxious because they did not know what the patients would ask and, therefore, could not adequately prepare for these questions. Pre-simulations, students perceived having observers as stressful but thought receiving feedback from them would be positive. Post-simulation, students reported that seeing the observers was stressful at first, but they forgot about the presence of the observers during the simulation. One participant said, “If the professor would have been in class during the activity (she) would have been more stressed.” Other participating students agreed and explained that they thought the professor expected them to act a certain way. They felt more comfortable interacting with a patient without thinking about performing according to the professor’s expectations.

Other external factors that were identified that influenced students’ anxiety levels were patient characteristics, feedback from observers, levels of preparation, and academic settings. The patient’s characteristics, particularly their language preference and cultural background, were a source of anxiety. The patient’s preferred language was a source of anxiety reported by two students who reported they were not fluent in the preferred language of either French or English. Two participants mentioned that the patient’s cultural background was a potential stressor. They both said their unfamiliarity with different cultures left them feeling uncertain about how to interact with these patients and concerned that their relationship with the patient would be compromised because of it. Post-simulations, most students reported that receiving positive feedback helped them feel more confident in their ability to complete simulation activities. Students also reported that feedback helped them understand what was expected of them and that the actor’s perspective was interesting. All students thought it was beneficial to receive feedback from observers with different roles (e.g., actors, dietitians, and other health professionals). Three students thought preparing questions for the interview was a good way to decrease their stress levels. Most students adapted how they were preparing for simulations to be more efficient. Most participants realized they did not need to control the conversation by following a detailed script. They adapted their approach and let the patients express themselves using more open-ended questions. Although information had been provided prior to the simulations, all students thought that the simulations would have been easier if more time had been dedicated to reviewing the topic of each simulation prior to the activity. Even if the simulations were not marked, most students still viewed the activity as an evaluation.