• Fedde Groot, Gersten Jonker, Myra Rinia, Olle Ten Cate, and Reinier G Hoff.
• F. Groot is a resident in anesthesiology, Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands. G. Jonker is anesthesiologist and a PhD candidate in medical education, Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; ORCID: https://orcid.org/0000-0001-6819-9990. M. Rinia is anesthesiologist, intensivist, and simulation instructor, Department of Anesthesiology, Rijnstate Hospital, Arnhem, the Netherlands. O. ten Cate is professor of medical education, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; ORCID: https://orcid.org/0000-0002-6379-8780. R.G. Hoff is professor of education and training in perioperative, intensive and emergency care, Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; ORCID: https://orcid.org/0000-0002-7432-7087.
• Acad Med. 2020 Jul 1; 95 (7): 1098-1105.

PurposeVygotsky's zone of proximal development (ZPD) refers to the space between what learners have mastered and what they should master in the next developmental stage. Physicians' tasks are ZPD activities for medical students, with high-acuity tasks such as resuscitation representing activities at the ZPD's frontier. This type of task can be taught and assessed with simulation but may be demanding and stressful for students. Highly challenging simulation may lead to a negative simulated patient outcome and can affect the participant's emotional state, learning, and motivation. This study aimed to increase understanding of the psychosocial and educational impact of simulation at the frontier of the ZPD.MethodThe authors conducted 11 phenomenological interviews between September 2016 and May 2017, to describe medical students' experiences with a challenging residency-level simulation test of acute care competence at the start of the final undergraduate year at University Medical Center Utrecht. Interviews took place within 2 weeks after the participants' simulation experience. The authors analyzed transcripts using a modified Van Kaam method.ResultsStudents experienced a significant amount of stress fueled by uncertainty about medical management, deterioration of critically ill simulated patients, and disappointment about their performance. Stress manifested mainly mentally, impeding cognitive function. Students reported that awareness of the practice setting, anticipation of poor performance, the debriefing, a safe environment, and the prospect of training opportunities regulated their emotional responses to stress. These stress-regulating factors turned stressful simulation into a motivating educational experience.ConclusionsSimulation at the ZPD's frontier evoked stress and generated negative emotions. However, stress-regulating factors transformed this activity into a positive and motivating experience.

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