How do they learn: types and characteristics of medical

RESEARCH ARTICLE Open Access

How do they learn: types andcharacteristics of medical and healthcarestudent engagement in a simulation-basedlearning environmentYashuang Wang1 and Yan Ji2*

Abstract

Background: Student engagement can predict successful learning outcomes and academic development. Theexpansion of simulation-based medical and healthcare education creates challenges for educators, as they musthelp students engage in a simulation-based learning environment. This research provides a reference for facilitatorsof simulation teaching and student learning in medical and health-related majors by providing a deepunderstanding of student engagement in a simulation-based learning environment.

Methods: We conducted semi-structured interviews with ten medical and healthcare students to explore theirlearning types and characteristics in a simulation-based learning environment. Thematic analysis was used toanalyse the data.

Results: The interviews were thematically analysed to identify three types of student engagement in thesimulation-based learning environment: reflective engagement, performance engagement, and interactiveengagement. The analysis also identified eight sub-themes: active, persistent, and focused thinking engagement;self-directed-learning thinking engagement with the purpose of problem solving; active “voice” in class; strongemotional experience and disclosure; demonstration of professional leadership; interaction with realistic learningsituations; support from teammates; and collegial facilitator-student interaction.

Conclusions: The student interview and thematic analysis methods can be used to study the richness of studentengagement in simulation-based learning environments. This study finds that student engagement in a simulation-based learning environment is different from that in a traditional environment, as it places greater emphasis onperformance engagement, which combines both thinking and physical engagement, as well as on interactiveengagement as generated through interpersonal interactions. Therefore, we suggest expanding the learning spacecentring around “inquiry”, as it can help strengthen reflective communication and dialogue. It also facilitatesimagination, stimulates empathy, and builds an interprofessional learning community. In this way, medical andhealthcare students can learn through the two-way transmission of information and cultivate and reshapeinterpersonal relationships to improve engagement in a simulation-based learning environment.

Keywords: Simulation-based learning, Medical and healthcare students, Student engagement, Medical andhealthcare education, Learning conducive environment, Facilitator-student learning relationships

© The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you giveappropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate ifchanges were made. The images or other third party material in this article are included in the article's Creative Commonslicence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commonslicence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtainpermission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to thedata made available in this article, unless otherwise stated in a credit line to the data.

* Correspondence: [email protected] of Nursing, Nanjing Medical University, Nanjing 211166, ChinaFull list of author information is available at the end of the article

Wang and Ji BMC Medical Education (2021) 21:420 https://doi.org/10.1186/s12909-021-02858-7

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BackgroundStudent engagement is a key topic that has become verypopular and widely researched in academia. Studies haveshown that student engagement can directly predictlearning outcomes [1], critical thinking skills [2], aca-demic achievement and learning satisfaction [3]. There-fore, student engagement has become an importantindicator of the quality of higher education. Countriessuch as the United States, China, the United Kingdom,and Australia have conducted national surveys of collegestudent engagement [4]. College student engagementusually refers to the time and effort that college studentsinvest in participating in activities with an educationalpurpose [5]. The classic “three-dimensional theory” ofstudent engagement identifies behavioural engagement,cognitive engagement and affective engagement. Behav-ioural engagement emphasizes participation, which re-fers to students’ participation in academic, social andextracurricular activities; Cognitive engagement empha-sizes investment, which refers to students’ willingness toinvest effort to understand complex issues and mastercomplex skills; emotional engagement refers to the posi-tive or negative reactions of students to facilitators,peers, school, etc., and their emotional reactions in theclassroom [6]. The “four-dimensional theory” includesacademic, social, cognitive and affective engagement.Academic engagement includes behaviours related todirect participation in the learning process. Social en-gagement includes students’ behaviour in observingclassroom discipline, lecturer-student interaction andpeer interaction. Cognitive engagement refers to thedeep thinking required to understand complex concepts.Affective engagement refers to the sense of identity andbelonging to the school [7]. The main difference be-tween the two theories is that the latter divides behav-ioural engagement into academic engagement and socialengagement.The diversity of learning fields gives rise to heterogen-

eity within the space and manners of medical andhealthcare student engagement. Some scholars havestudied medical and healthcare student engagement inthe clinical environment by using the Moodle system,which is based on the visual learning environment. Theyfound that students adopted a strategic learning ap-proach in the clinical environment by using more Inter-net resources to answer medical questions under timeconstraints, in comparison to traditional learning tech-niques wherein students obtain information from books[8]. Medical and healthcare student engagement is alsoreflected in tasks that simulate clinical situations and on-line settings. Some scholars have studied the degree ofmedical student engagement in interprofessional co-operative communications and have researched theemotional obstacles to the e-learning engagement of

medical students, including a sense of injustice, passivityand feeling overwhelmed [9, 10]. Increasingly, studiesare conducting in-depth analyses of student engagementwith different curricula and teaching styles. Researchersfound that greater use of cognitive engagement, such aselaboration and critical thinking, is associated withhigher levels of student performance in a medical grossanatomy course [11]. In addition, reflective writing exer-cises were found to be more likely to be an effectivestrategy than grades for fostering student engagement inmedical humanities courses [12]. Research has also beenconducted on the relationship between different learningstyles and student engagement [13].Medical and healthcare education is media- and

resource-dependent in nature. It has become increas-ingly prevalent to integrate technology-enhanced learn-ing (TEL) resources and promote the reform ofinformation technology (IT)-based teaching models inhigher medical and healthcare education [14]. The mostrepresentative example in the field is simulation-basedmedical and healthcare education, especially high-fidelitysimulation, which can bridge the gap between theoryand practice by immersing learners in a realistic setting[15]. In recent years, simulation-based training has seenincreased popularity in global medical and healthcareeducation, and many discussions have been held on theinevitable reforms and future development trends [16].The aim of such training is to improve the competenceof medical and healthcare professionals, ensure the qual-ity of medical and healthcare, and promote patientsafety. Simulation-based education is conducted in asimulation-based learning environment. In contrast withtraditional classrooms, the newly developed strategiesand instructional methods(e.g., simulated clinical envir-onment laboratory learning, virtual simulated equip-ment, team-based learning, problem-oriented learning,scenario, role-playing, virtual or standardised patients)profoundly change students’ learning environment andlearning methods.Driven by this movement, educators have begun to

focus on medical and healthcare student engagementwith the IT-based learning environment. Most researchfocuses on the effect of using IT in the objective physicalenvironment and the impact of teaching methods onstudent engagement; such methods include classroommobile technology [17], online learning aids [18], onlinetests [19], visualised virtual patients [20], audience re-sponse systems [21], simulation training [16, 22], etc.Many existing studies, including those listed above, focuson the impact of IT on student engagement, but little isknown about what and how student engagement itselfhas changed. Medical and healthcare simulation-basedtraining has changed traditional teaching and learningmethods, and this has had a profound impact on the

Wang and Ji BMC Medical Education (2021) 21:420 Page 2 of 13

types and characteristics of student engagement. Thesimulation-based learning environment also poses chal-lenges to the original classification and measurement ofstudent engagement type within traditional classrooms,raising questions as to whether the original frameworkmay still be applicable for the simulated environment.By studying medical and healthcare student engagementin the new learning environment and classifying thetypes and characteristics of student engagement, adjust-ments can be made to the teaching approaches that canhelp medical and healthcare students engage in mean-ingful learning in a more targeted manner.At present, quantitative research is the most common

research paradigm for studying college student engage-ment. However, many scholars have questioned the reli-ability and validity of the questionnaires usingquantitative research and the validity of student re-sponses [4, 23]. Researchers point out that student en-gagement is a complex, dynamic and contextualisedconcept that cannot be measured solely by quantitativesurveys. Furthermore, students are prevented from ex-pressing their thoughts beyond the questions within thequestionnaire [24]. Therefore, current and future re-search methods should not be limited to large-scalequestionnaires but extended to encompass multiplemethods, including qualitative research because of itsstrength and suitability [25].Medical and healthcare education has always been

highly contextualised in a specific historical, ethnic, andregional development setting. The simulation-basedlearning environment involves various contextualisedlearning activities and practices that resemble real-lifepractice and experiences. The study of medical andhealthcare student engagement in this environmentneeds to shift from the traditional quantitative researchparadigm to a qualitative paradigm, as the latter canoffer more insights into the interactive mechanisms be-tween college students’ learning behaviour and the en-vironment. Thus, the purpose of this study is to explorestudent perspectives following simulation-based learningto gain a more complete understanding of their engage-ment within the learning environment.

MethodsInterprofessional education courseThe 10 participants all participated in an interprofes-sional education course that 48 students had taken as anoptional course before the interview. The course has 10teaching periods, each lasting 2 h. Seven periods wereconducted in the discussion room, which was staffed by1 tutor and 1 teaching assistant. Students were requiredto discuss cases in groups and reflect upon the profes-sional value of their roles in the case. Students per-formed high-fidelity simulations in the laboratory twice

accompanied by 3 tutors, one for “Neonatal respiratorydistress syndrome rescue” and the other for “The rescueof cardiac and respiratory arrest patient with coronaryheart disease”. Students in groups played different rolesto run the case. Students made desktop deductions inthe discussion room once under the guidance of 3 tu-tors, the theme of which was “The rescue of a largenumber of injured people suffering after a sudden explo-sion in the emergency room”. Students needed to usethe hospital department plan, teaching aids, etc., to con-duct an interactive discussion and engage in emergencydecision-making and on-site actions instead of runningthe case. Every simulation study carried out in the la-boratory included three steps: 1. Orientation, includingan introduction to the learning objectives and the oper-ating environment of the case. 2. Simulation, where stu-dent ran the cases. 3.Debriefing, when the facilitatorsgave feedback to the students and summarised their per-formance in the laboratory.

Semi-structured interviewsQualitative research commonly uses semi-structured in-terviews, as these enable participants to reflect on pastexperiences and to generate new ideas on how to pro-mote student engagement as they engage in retrospec-tion. This process can shed light on useful and effectivelearning strategies. The main interview questions includethe following: (1) How does student engagement andparticipation unfold in a simulation-based learning en-vironment? What are the characteristics of that engage-ment and participation? (2) What are the differencesbetween student engagement in the simulation-basedlearning environment and learning in traditional class-rooms? (3) To what extent do you think you haveinvested more in student engagement in a simulation-based learning environment? The concrete content isshown in Interview Guide. After obtaining consent, weconducted the interviews. When collecting data, wewould engage in “epoche” and suspend our previous the-oretical views, allowing participants to express their per-sonal feelings without restriction, and we tried to helpthem to speak to as many real and comprehensive feel-ings and different experiences as possible to obtainricher themes and a more comprehensive display of thedifferent types and characteristics of studentengagement.During the interviews, the researchers conducted in-

depth exploration, mainly around these open researchquestions, but always allowed the interviewees to fullyexpress their thoughts without interference. Follow-upquestions and investigative questions were asked ifneeded. Follow-up questions were used when re-searchers were very interested in the views the inter-viewee was stating and wanted to have a deeper


understanding, in which case the researchers asked theinterviewee to give more detailed information. Investiga-tive questions are a technique that allows the discussionto continue while obtaining further clarification, whichhelped us manage the conversation with the intervieweeso that it always revolved around the main researchquestions. We used some simple phrases, for example,“You did a good job, please continue”, to suggest the dis-course depth we needed from the interviewees or to en-courage them to further expand the conversation. Allresearchers used almost the same main questions andinterview techniques for the 10 interviews, and inter-viewees could fully express their views about these broadquestions. However, the researchers also reflected uponthe interview recording after each interview with 2 stu-dents to better guide the next interview.

ParticipantsThis study used the principle of purposeful sampling,i.e., non-probability sampling, to select interviewees thatwould allow them to draw the maximum amount of in-formation for the research questions in light of the re-search purpose [26]. We followed the followingstrategies: (1) participants were selected who could pro-vide essential and sufficient information regarding theresearch questions to enhance the intensity samplingprinciple. That is, in the current study, priority was givento participants who were interested in the research topic,good at expression, open-minded and willing to sharetheir experiences with others. (2) Adhering to the max-imum difference sampling strategy [26], the resultsshould reflect the heterogeneity within various learningexperiences to the greatest extent, accounting for factorssuch as majors and sex that have proven to influencestudent engagement. First, according to the above sam-pling strategies, after communication with their instruc-tors, we chose students who were active, highly engaged,and good at sharing in the classroom to be our inter-viewees. We selected a total of 10 students from

different majors, adopting the snowball samplingmethod, who were recommended by the interviewees.They were all sophomores at a medical university inChina. The descriptive information is shown in Table 1.Our choice was based on China’s medical educationcontext. In China, there are many independently estab-lished medical universities that recruit students majoringin clinical medicine, nursing, preventive medicine, andrehabilitative medicine. In the management of medicaleducation at the national level, medical education-related documents are issued by the state, and clinicalmedicine, public health, rehabilitation, nursing and othermajors are included in the scope of medical educationfor unified management. The students were numberedaccording to the initials of their professional names andsorted by number.

Data analysis procedureThis paper was informed by an approach based on the-matic analysis [27]. Data collection and analysis werecarried out simultaneously; that is, we conducted thedata analysis immediately after interviewing 2 partici-pants. The determination of the specific number of in-terviewees generally followed the “theoretical saturationprinciple”: when the newly extracted information aboutthe types and characteristics of the interviewees’ learningengagement no longer contributed to new coding, add-itional interviews would not be carried out. All the inter-views were audio recorded. In the process of thematicanalysis, our own theoretical views on student engage-ment in a simulated learning environment provided thebasis for in-depth dialogue with the materials. This studyconducted interviews in Chinese, taking into accountthat the use of one’s native language allows the partici-pants to more accurately reflect their ideas, and it fol-lows the trend in which native languages are morefrequently being used in qualitative research [28]. Twoauthors of this article, the first author majoring in Eng-lish at the undergraduate level, translated the article.

Table 1 Basic information and numbers of the students interviewed

Serial Number Profession Grade Sex Age range Numbering

1 Nursing Two Male 18 ~ 21 H1

2 Clinical medicine Two Female 18 ~ 21 L1

3 Preventive medicine Two Female 18 ~ 21 Y1

4 Nursing Two Female 18 ~ 21 H2

5 Health Care Management Two Male 18 ~ 21 W1

6 Nursing Two Female 18 ~ 21 H3

7 Clinical medicine Two Male 18 ~ 21 L2

8 Imaging Science Two Female 18 ~ 21 Y2

9 Health Care Management Two Female 18 ~ 21 W2

10 Rehabilitation medicine Two Male 18 ~ 21 K1


Additionally, three scholars were invited to conduct astrict review of the translation, two of which had studiedand obtained doctoral degrees in English-speaking coun-tries, and the other held a master’s degree in English.This process ensured a professional translation whereintranslation errors would not affect the research results.We emailed the completed transcription to the partici-pants, and they verified the transcribed text and redactedany information that they did not want used in thecurrent study. We coded and analysed each text to findany content related to the research questions and identi-fied the concepts and topics associated with the researchinterest. Before the analysis, the two authors discussedthe theoretical framework, reached an agreement, andthen analysed the transcripts independently. After theindependent analysis, they resolved coding discrepanciesand chose more appropriate coding and themes. Thetexts were organised and analysed by MAXQDA qualita-tive data analysis software version 10, with meaningfulwords, phrases, sentences, and paragraphs marked witha specific code. After the text data were coded, the codeswere classified according to the theme. We then

established a category and finalized the correspondingmodel framework. The final generic list is shown inTable 2.

ResultsThe characteristics of student engagement in thesimulation-based learning environment were sum-marised into three types: reflective engagement, per-formance engagement and interactive engagement.Furthermore, sub-themes were identified, as describedbelow. Table 3 containing the themes, subthemes andsample quotes is shown below.

Reflective engagement with the purpose of problemsolving and active thinkingEngaging in active, persistent, and focused thinkingOne of the most significant features of cognitive per-formance in a simulation-based learning environment is“active reflective engagement”. Many participants in ourstudy emphasised in the interviews that this is a kind ofactive thinking and active engagement. Different fromthe short-term thinking in traditional classes, the

Table 2 List of medical students’ learning categories

Secondary Coding Classification Create A Generic LearnEngagement Type

Focused, very focusedWhole heartedly involvedActive thinkingComprehendFind problems, analyze problems, solve problemsObserve and listenRespondRecord, write and reflect;

Concentrate onConcentrationMind and BodyInvolvementActive ThinkingProblem FoundAnalyze ProblemSolve the ProblemWatch and ListenSubmit QuestionsExpress OpinionsRecord Reflection

ReflectiveEngagement

Upset, excitement, tension, excitement, eagerness to try, expectation; enthusiasm, joy, happiness, joy,excitement, sense of accomplishment;Discomfort, inferiority, depression, disappointment, loss, condemnation, guilt,Relax, tense; unconvinced, regret;Emotional expression, full of emotions;Strong emotional expression and indifferent emotions;Play a roleLeadership, assignment of tasks, core members;Actual operation;Show oneselfNot absent during important times

Positive EmotionNegative EmotionEmotional ExpressionEmotional FillingStrong MoodIndifferentCosplayLeadershipCore MemberActual OperationStrict Attendance

PerformanceEngagement

Immersive performanceRescue senior simulators and interact with themIdentify peer issues;Drive peers;Discuss, communicate and communicate within the profession;Peer awarenessPeer collaborationAsk questions;Observer, questioner, helper, prompter;Teacher guidancePositive teacher feedback

As It IsContextual InteractionPeer CorrectionDrive CompanionsProfessionalCommunicationPeer AwarenessPeer CollaborationAsk QuestionsIdentity ChangeTeacher GuidanceTeacher Feedback

InteractiveEngagement


simulation-based learning environment requires con-stant and persistent thinking. Another frequently usedword is “focus”. Students who were highly focused in asimulation-based learning environment were deemed tohave a “strong and attractive energy field” [L1]

“[In traditional classrooms] Sometimes students areasked some questions but given limited time for a re-sponse. Many times, the class continues without giv-ing enough time for student’s reflection on thequestions.” [L1]

Table 3 List of themes, sub-themes and sample quotes

Themes Sub-themes Sample quotes

Reflective engagement with the purpose ofproblem solving and active thinking

active, persistent, and focusedthinking engagement

Everyone knows what they want to do, what tasks theyhave to accomplish, and how they can cooperate withothers. In this way, our way of thinking is dedicated towardswhat we take the initiative to think about, what we want todo. We also take the initiative to complete our own tasks,start proactive communication and cooperation with others.In this sense, everyone’s way of thinking has become moreactive.

self-directed-learning thinkingengagement with the purposeof problem solving

I feel more self-driven to solve the problems if they comeup. I do not rely on facilitators to guide me to solve theproblem. After all, I cannot just leave the problem therewithout doing anything … what is more important is theway of thinking. That is, how to find problems and how tofind better ways to solve problems.

active “voice” in class When the student listens to the facilitator very carefully andasks questions; or when analysing the case, the student canpolitely interrupt others in a timely manner, and give theirown opinion... especially when the questions they ask areconstructive, or if they really help others to think moreabout the questions.

Performance engagement characterised by strongemotional expression and leadership

strong emotional experienceand disclosure

When we perform a live simulation in the laboratory, first ofall, there is a sense of tension. You have to complete thetasks given by the facilitator. You don’t know if you can doit well. Second, when we engage in this work, we can easilyreveal our emotions regarding whether the work progresseswell, whether the result is good, and what has happened inthe process. For example, if something goes wrong or whenwe make a mistake, we will be very anxious, there may be asense of shyness and even shame. In short, our moods arefully revealed.

demonstration of professionalleadership

When the leader is directing the group, the leader will dotheir job meticulously. This includes how many peopleshould be allocated to every activity and what everymember should do... when the leader organises everythingvery thoroughly, I can tell that the leader is very engaged atthat time.

Interactive engagement as a result ofmultidimensional interactions between learners,learning communities and the environment

interaction with realistic learningsituations

Children can survive by double-compression. I feel that Ihave to do a good job... and then I would carefully read thematerials given by the facilitator and then delve deeper intothe textbooks. I want to successfully rescue the baby... be-cause the baby would cry despairingly, that would makethe atmosphere very intense... and then the sense of ur-gency in that situation is much stronger than the pressureimposed by facilitators or exams in reality.

support from teammates In order to complete a group task, we need mutualencouragement and support. I feel that someone islistening and someone is willing to respond to you. Thissense of mutuality is very fulfilling and very encouraging.During interaction, I can feel the kind of enthusiasm of theclassmates. They are motivated to do the task because theyreally value the patient and imagine what if the sameexperience should happen to them.

collegial facilitator-studentinteraction

The facilitator, as an observer and a questioner, is not ananswerer, um, is a helper, a prompter. The facilitator is moreeasy-going. The sense of distance and barriers areeliminated.


“[In a simulation-based learning environment] If youdon’t take time to think about it, the patient in frontof you may die, and you will feel a strong sense ofguilt ... if you don’t solve the problem, things won’twork out. I will try my best to do it, not to give uphalfway ... unlike in a traditional classroom, whenthe facilitator asks a question, you just need to givea standard answer and it all ends.” [H1]

The simulation-based learning environment also al-lows students to be more focused on listening to the fa-cilitator. They feel that they must take the lessonseriously because the follow-up session contains real-lifepractice.

“In traditional classrooms, sometimes the facilitatortalks too fast, and you will feel a bit unwilling to lis-ten ... In the simulation-based learning environment,there is very little possibility of being distracted, youcan focus more on the facilitator, and you can takemore notes.” [W2]

Self-directed-learning thinking engagement with thepurpose of problem solvingStudents must familiarise themselves with the knowledgebefore entering the simulation-based learning environ-ment. This is different from the passive learning prac-tices in traditional classrooms, where students justfollow the facilitator’s thinking, being instead a re-understanding of the original learning process and out-comes. Students are able to experience the self-directedlearning process of constructing self-knowledge throughobservation, reflection, practice, problem discovery andresolution. Problem solving is the driving force of think-ing activities, and the thinking process is reflected in theprocess of problem solving.

“I feel more self-driven to solve the problems if theycome up. I do not rely on facilitators to guide me tosolve the problem. After all, I cannot just leave theproblem there without doing anything … what ismore important is the way of thinking. That is, howto find problems and how to find better ways to solveproblems.” [H1]

Problem-solving reflective engagement is accompaniedby close connections between knowledge. Because itsolves real-life problems, the knowledge being connectedis situated in a multidisciplinary context, and the voicesof the patients are also being heard.

“In a normal session of your major, you just pas-sively accept theoretical knowledge. You would notevaluate doctor-patient relationship from multiple

perspectives, such as the potential influence over so-ciety and a humanistic perspective. I think my wayof thinking has become more active.” [Y1]

The process of problem solving is usually accompaniedby communication and mutual affirmation among peers.When questions and thinking are valued, students aremore motivated to think actively.

“If you have your own thinking and vocalize it,everyone will listen more carefully to your sugges-tions and then put forward their own views... yourown thinking is built up or challenged by others,which pushes you to do more active thinking.” [L1]

Active “voice” in class“Speaking” in the classroom is another important mani-festation of reflective engagement. On the one hand, anindividual has more opportunities to ask constructivequestions than in the simulation environment. On theother hand, unlike the commonly seen shyness and si-lence among East Asians [29], in a simulation-basedlearning environment, students are more willing to ac-tively engage in conservations and answer questionsraised by peers.

“I am more involved than usual in [simulation]class. In traditional classrooms, students just sit inclass and dare not answer facilitators’ questions.And now [in simulation class], if your peer asks youquestions, you can quickly give a response, since if noone knows the answer, the game will not continue.The facilitator usually asks questions in class. Theclass gets embarrassing if no one speaks ... [in simu-lation class] I feel the need to talk about it myself,whereas there is no such feeling in [traditional]class.” [H2]

In regard to the reasons why students want to speakup more in a simulation class, many participants thinkthat “because of the group-discussion format, the groupactivities ease the classroom tension, which makes youmore relaxed and can stimulate your thinking.”[Y1].

Performance engagement characterised by strongemotional expression and leadershipStrong emotional experience and disclosureLearning in a simulation-based learning environmentusually requires students to play different roles, such asdoctors, nurses, patients, and family members. Throughthese exercises, the students are expected to be familiarwith the different roles to achieve the learning goals.Therefore, they often claim to be students from “a cer-tain performing university” or “a performance major”.


The description “acting elf” is often used to refer tothose who are particularly good at acting.Performance means that it is necessary to channel

emotions into the character and act out that character’sbehaviours. The current study found that strong emo-tional experience and disclosure are an important mani-festation of performance engagement.

“As far as I observe, the extent of student participa-tion is diverse. Some people more actively partici-pate, while some individuals are indifferent toemotional performance if they don’t pay much atten-tion to this course.” [W1]

The emotions in the simulation-based learning envir-onment change in accordance with the progress of prob-lem resolution and are most often associated with theoutcome of the patient. There could be “unconscious-ness, excitement, tension, eagerness, expectation” whenthe situation of the “patient” is unknown; there could be“happy feeling, confidence, excitement and a sense offulfilment” if the operation is successful; there could alsobe “regret, discomfort, guilt, inferiority, depression, de-pression and feeling lost, unconvinced or even con-demned” when the operation fails.Strong emotional engagement enables students to be

physically and psychologically involved in learning activ-ities, contributing to a state of “presence”.

“That kind of atmosphere [in a simulation environ-ment] is different. The physical environment andlearning atmosphere affect my psychological stateand make me more focused on being involved in thetask. I do not feel like just physically being in a class-room while mentally distracted by something else.”[H1]

Many students even enter a state of “flow” when theyfully immerse themselves in the tasks.

“In the laboratory, I don’t care too much about howlong the course takes. I think even if this class over-runs, I won’t be too bothered.” [H2]

Emotions and feelings are attitudinal experiences stim-ulated by a sense of “need” and revealed through behav-ioural outcomes. Although emotions and feelings areinspired by objective experiences, their nature is deter-mined by people’s perception of the situation [30]. Dur-ing the interview, some participants compared emotions,describing them as more “calm” in traditional class-rooms but “fuller” in the simulation-based learning en-vironment. Compared with the traditional classroomatmosphere, which suppresses the expression of

emotions, a more relaxing simulation-based learning en-vironment helps release various emotions.

Demonstration of professional leadershipThe simulation-based learning environment usually cre-ates a realistic hospital scene. In this atmosphere, thereare many actions that reflect professional leadership.These include whether one can take the initiative to takeresponsibility as the leader, whether one can lead theteam to facilitate the learning process, or whether oneactively follows the leader, quickly adjusts to the role,analyses problems, and offers responses. A deeper levelof participation is reflected when those “leaders” usetheir knowledge and demonstrate their capabilities. Assome participants said,

“Some people will take the responsibility of leader-ship voluntarily and spontaneously assign people todo certain things. I will consider that person very de-voted and motivated. For those who follow the lead,I also think that they are thinking deeply and en-gaged entirely”. [L1]

Interactive engagement as a result of multidimensionalinteractions between learners, learning communities andthe environmentInteraction with realistic learning situationsThe most prominent feature of the interactive learningenvironment is the realistic working session, includingmimicking the busy atmosphere as well as the vivid“doctor-patient” interactions in a physical hospital setup,which enable students to be fully drawn to the learningcontext.

“The more realistic the environment is, the strongerfeeling I have that similar situations would happenin real life practices.” [K1]

“At the time, the assessment involved a little baby[model] ... we played with him, and we felt a kind ofattachment. We would say, ‘look at those babies’.There would be a kind of motherly love – a kind offeeling expressed spontaneously.” [L1]

The professional responsibility of medical and health-care students is also stimulated by the simulated envir-onment, which fully brings medical and healthcarestudents into their professions.

“For example, if you rescue the senior simulator suc-cessfully, it will give out some responses. For ex-ample, during the rescue, the student can monitorthe “patient’s” pulse, blood pressure etc. ... in thatsimulated context, because of the role you play, you


will develop a strong sense of responsibility and wantto do it well.” [H2]

“I will subconsciously think that I am a professionaland I can do this well. Then, I will not be distractedby others, since I just need to do the operation basedon what I have learnt. Building on that, I will alsothink about how I can better use the knowledge.”[H2]

This sense of professional responsibility also motivatesstudents to achieve a higher level of engagement.

“I'm probably more engaged at that time [in the sim-ulated learning environment] than I would be if Iwere alone. That is, when someone wants to interactwith you, it makes me feel that this is not my ownbusiness. It is not like normal practice, which issolely operated by a single student, which easilymakes one lonely and bored. Because there are inter-actions in a strongly collaborative atmosphere, whichpromotes my sense of responsibility. That is, if I do itwrong, my teammates will have to bear the conse-quences too, so it is not my own business.” [H3]

Support from teammatesPeer interaction is mainly manifested in the sharing ofinformation, mutual discussion, and skill guidance re-quired in the process of problem solving.

“You exchange views with your peer... and jointlysolve this problem, which leads to increasing peersupport.” [K1]

Unlike ordinary peer communication, in thesimulation-based learning environment, peers are moreconscious and conduct more in-depth communicationwithin the profession and develop the ability to thinkabout problems holistically.

“What are their [my peers’] concerns? What are myconcerns? What are the similarities and differencesbetween my peers’ and my own concerns?” [H1]

The “companion” in the simulation-based learning en-vironment is not simply a learning partner but a buddywho needs to complete a task that is very challenging.The mutually facilitative interaction between peers pro-motes active engagement. However, if the interaction isnot harmonious, it will hinder further engagement. At-tentiveness and responsiveness from peers will drive thenext round of positive emotional experience and studentengagement.

“If everyone is very cooperative and actively partici-pates, the interactions will be smoother, it will havea more positive effect on participation. If everyone iscold and everyone does not want to talk, then thistask cannot carry on.” [H3]

The impressive performance of other students in theprocess of peer interaction also motivates the studentsto be more engaged.

“The students who participated in that course arevery active and full of positivity. I enjoy interactingwith them, and I am willing to speak up if I feel likeit... when my classmates are thinking about the prob-lem very seriously and trying to solve the problem, Ifeel that I can’t stand by but need to help out.” [K1]

“Especially if your peers are very good at acting, theyconvince you that the entire process is very authenticand make you more engaged in solving the prob-lems.” [H2]

The collegial facilitator-student interactionThe role of the facilitator in the simulation-based learn-ing environment is more that of a guide, directing thestudents forward instead of just giving them answers.Furthermore, they provide students with ample space forthinking. The facilitator also takes on the role of “dir-ector”, setting up scripts and scenes, observing the ac-tors’ performance, and giving guidance. “The facilitator,as an observer and a questioner, is not an answerer, um,is a helper, a prompter.” [H1] The facilitator-studentinteraction in the simulation-based learning environ-ment is more “easy-going” and “informal” than that inthe traditional classroom.

“The facilitator also participates. The facilitator andwe students feel like friends. Unlike in the classroom,where one needs to be more respectful when askingthe facilitator questions, there is no distinct bound-ary between the facilitator and students in a simu-lated learning environment.” [L1]

“The facilitator is more easy-going. The sense of dis-tance and barriers are eliminated.” [Y2]

The facilitator-student relationship in the simulation-based learning environment is based on a more equalfooting, as there is no hierarchical relationship duringknowledge transfer. Instead, the facilitator acts as a con-sultant. If students are given positive feedback and af-firmation in a timely manner, they will be more willingto participate.


“That is to say, the facilitator has high expectationsfor us. Thus, we must definitely treat the course ser-iously and put in more effort so as not to disappointthe facilitator.” [W1]

DiscussionThis research is the first to study the feelings and experi-ence of medical and healthcare students in a simulatedlearning environment from the perspective of studentengagement. Based on the findings, it reclassifies thetypes of student engagement, forming a new student en-gagement type that fits the simulation-based learning en-vironment and differs from the classic studentengagement type. Our research divides student engage-ment into three dimensions: reflective engagement, per-formance engagement and interactive engagement.Compared with the dimensions of traditional learningengagement models, it fully considers performance en-gagement, which is a combination of thinking and phys-ical engagement in a simulation-based learningenvironment, and the engagement generated by inter-personal interactions; these additions are innovative andshow the characteristics of learning in a simulation-based teaching environment.

Types and characteristics of medical and healthcarestudent engagementThis study provides insights into medical and healthcarestudent engagement in a simulation-based learning en-vironment, finding that it involves reflective engagement,performance engagement, and interactive engagement.Reflective engagement is problem-oriented, with a focuson inducing active, persistent and focused thinking prac-tices. It involves a deep, reflective and concrete process-ing activity. As D. H. Jonathan states, “learners learnfrom thinking, but not from technology” [31]. Even in asimulation-based learning environment using advancedtechnology, the fundamental principle is still to stimulatestudents’ persistent, active and focused reflective engage-ment. Reflective engagement is a primary type of studentengagement among medical and healthcare students, asstudents use it to reflect upon and practice existingknowledge. A literature review also suggested that an in-creasing emphasis is being placed on reflection and re-flective practice in medical curricula [32]. Throughreflective engagement, students are able to fully utilisecritical thinking to obtain an in-depth understanding,construct advanced knowledge to create a bridge be-tween knowledge and experience, facilitate supportivepeer interactions and reduce the amount of “silence” inclassrooms.The study also found a special form of student engage-

ment in a simulation-based learning environment,namely, performance engagement, which is role-based

emotional and behavioural engagement. It promotes em-pathetic experiences, facilitates interprofessional practiceand encourages a stronger desire for leadership. Similarto findings in the research conducted by Ulrich et al.,role play simulation allows participants to actually feelthe emotions they might experience in the future anddevelop their professional values [33]. Emotional engage-ment is an important aspect of medical and healthcarestudent engagement. Cognitive scientists tell us thatlearning is a multilevel communication process at thecognitive, emotional and physiological levels. However,this study also found that, unlike the positive emotionsin general student engagement, which positively affectlearning outcomes [34], mixed emotions are experiencedby medical and healthcare students in simulation-basedlearning environments. Many participants consideredthat, as long as the affective level was high, all emotionsand feelings indicated engagement. The special need inmedical practice to manage doctor-patient relationshipsand intense emotional responses makes the emotionaldevelopment of students particularly important in med-ical and healthcare education. Medical and healthcarestudents need to develop the emotions of compassion,care and empathy, and to develop moral sensitivity andemotional regulation. These findings are in accordancewith those on the value of emotional intelligence inmedical and healthcare education, with increasing re-search evidence showing that doctors’ emotionalintelligence can improve their ability to deliver safe andcompassionate health care [35]. In this way, they can al-ways manage the balance within an emotionally rich en-vironment to avoid emotional burnout. Medical andhealthcare educators need to understand how emotionsdevelop and how technology facilitates emotional devel-opment. The simulation-based learning environmentalso creates a more vivid professional identity for stu-dents beyond the pure learner status. Students showgroup or individual leadership when they “act in the pro-fessional role”; this process confirms that the integrationof technology into teaching helps promote students’ in-dividual psychological functions from purely cognitivedevelopment to meaning acquisition and the dual devel-opment of identity.Interactions within student engagement are reflected

in the responses to the high-fidelity simulator, mutuallysupportive peer interactions and collegial facilitator-student interactions in a realistic simulated environment.The origin of learning is the real-world construction ofenvironmental and social interaction. The application ofemerging technologies such as virtual reality and aug-mented reality has gradually turned the simulation-based learning environment into an important learningspace for medical and healthcare students [36]. In thisspace, peers, facilitators and students constantly


construct knowledge through interactions and cooper-ation. Teamwork is crucial for success: varied back-grounds and interests enable students to solve theproblems from different perspectives [37]. Eismann et al.showed that simulation courses have an influence onteamwork [38]. The current study found that the moreclosely the learning context is related to real-life prac-tices, the more mutual encouragement takes placeamong peers along with more positive feedback fromthe facilitator, which in turn promotes student engage-ment. Similarly, as studied by Behrens et al., well-designed clinical scenarios, teamwork and feedback sup-port students’ learning [39].

Logical relationships between different types of studentengagementMedical and healthcare student engagement in asimulation-based learning environment promotes stu-dents’ whole-hearted focus. Specifically, reflective en-gagement facilitates deeper levels of critical thinking andknowledge construction; interactive engagementemerges from interactive activities in the learning space;and performance engagement gives rise to role-basedgroup activities, promoting participation and reflection.These three forms of engagement are subject to the in-fluence of many environmental and pre-existing factors.For instance, when students engage with the roles theyplay, they need to constantly reflect on the role’s behav-iours, feelings and thoughts while modifying their actingbased on their knowledge and previous experiences.Step-by-step practices and immediate stimuli in thelearning environment prompt more reflections, encour-aging students to continuously conceptualise and actupon their experience; at the same time, they facilitatethe interaction between the character and the externalenvironment, thereby forming a relationship framework.Medical and healthcare students’ reflective engagement,performance engagement and interactive engagement in-fluence each other. The use of IT highlights the multidi-mensional interaction between individuals, groups andthe technology environment.The findings indicate two perspectives that explain the

mechanisms behind student engagement: the two-wayconstruction of individuality and space in learning andthe interdependence of the learner and the learningcommunity. Facilitators can improve their teaching in asimulation-based environment accordingly. First, interms of the promotion of reflective engagement,expanding the learning space centring around “inquiry”helps strengthen reflective communication and dialogueand further facilitates the process of knowledge con-struction. Before the simulation teaching, the facilitatorcan use the learning situation analysis method to analysethe students’ existing knowledge base. In the orientation

stage, facilitators help the students fully review the case-related knowledge, making students convert the know-ledge into action when they operate the case. In thedebriefing stage, facilitators guide students’ reflection,asking them to determine three to five drawbacks aboutthemselves or their peers and provide answers. Afterclass, facilitators assign reflective learning homework,such as asking students to complete a reflective diary tohelp them improve their reflective skills.In terms of promoting performance engagement, facil-

itators need to set the stage with a relevant and realisticscenario [40]. First, it is necessary to write cases basedon realistic clinical scenarios, for example, ensuring thepatient’s symptoms and signs are in line with the devel-opment of the disease, real and challengeable. The plothelps students develop clinical reasoning ability. Second,it ensures that the environment of the simulation labora-tory is close to that of the real clinical environment, suchas the placement of instruments and equipment. Finally,it guides students on how to show real emotions whenperforming but also pays attention to the emotionsshown by the other characters to that they can displayempathy. Facilitators should encourage exchanges andinteractions between students of different majors,thereby promoting the establishment and developmentof professional responsibility and professional leadership.Interprofessional education research evidence provides aclear indication that it can improve collaborative atti-tudes/perceptions and the knowledge/skills necessary forcollaborative practice [41].In terms of promoting interactive engagement, the role

of the facilitator should be changed from impartingknowledge to guiding and helping. For example, whenthe case is not operating smoothly, the facilitator shouldintervene in a timely manner to promote the case. In thedebriefing stage, the facilitator should guide students asthey think about the learning goals that should beachieved and their current learning level, as well as thegap between the two. In promoting peer interaction, theaccountability method requires students to take respon-sibility for their roles, and the self-evaluation and peerevaluation methods allow students to provide feedbackon themselves and their peers, respectively, to promotepeer-to-peer interaction.

LimitationsThe purpose of this research is to reflect on student en-gagement in a simulation-based learning environmentfrom students’ perspective, offering a basis for referenceby facilitators to improve their methods of instruction.However, this is also a limitation of this research, whichfails to make judgements about students’ learningachievements in combination with their objective learn-ing performance. Our follow-up research direction is to


overcome this limitation. This research focuses on thelearning experience and subjective feelings of students inthe simulation laboratory. However, we cannot knowtheir possible reactions in the real world, nor can weknow whether the learning experience in the laboratorywill affect their performance in the real world. This isalso a possible future direction of our research.

ConclusionsStudent engagement in a simulation-based learning en-vironment is different from that in the traditional class-room. The current study provides evidence for theunique nature of simulation teaching, which promotesreflective learning and immersion in a clinical environ-ment while facilitating reflective engagement, perform-ance engagement and interactive engagement. Thesethree types of student engagement help them to achievethe expected learning result through the two-way con-struction of individuality and space in learning as well asthrough the interdependence between the learner andthe learning community.

AbbreviationsTEL: Technology-enhanced learning; IT: Information technology.

Supplementary InformationThe online version contains supplementary material available at https://doi.org/10.1186/s12909-021-02858-7.

Additional file 1.

AcknowledgementsWe would like to thank the participants for their involvement in this study.

Authors’ contributionsJY contributed to the design of the study, ethics application and acquisitionand analysis of data. WYS interpreted the data and drafted and revised themanuscript. Both authors read and approved the final manuscript.

FundingThis study was supported by the 2018 Jiangsu Social Science Foundation(18JYB004) and the Medical Education Branch of the Chinese MedicalAssociation and the Medical Education Professional Committee of theChinese Higher Education Association Medical education research project in2018 (2018B-N17013). The founders of these organizations have no role inthe study design, data collection and analysis, interpretation of data, orwriting the manuscript.

Availability of data and materialsAs these data are semi-structured interviews, raw data will not be madeavailable to protect participant confidentiality.

Declarations

Ethics approval and consent to participateThe study was approved by the Nanjing Medical University EthicsCommittee. All participants were asked whether they would like to acceptthe interview. Those who agreed to do provided verbal consent toparticipate and for the data to be used in publication.

Consent for publicationNot applicable.

Competing interestsThe authors declare that they have no competing interests.

Author details1Institute of Education, Nanjing University, Nanjing 210093, China. 2School ofNursing, Nanjing Medical University, Nanjing 211166, China.

Received: 4 June 2020 Accepted: 28 July 2021

References1. Peng MYP, Wang RS, Liu FC, Tuan SH. Multi-engagement, learning approach

and student learning outcomes: evidence from Taiwanese Private University.Univ J Educ Res. 2017;5(7):1137–44.

2. Williams L, Lahman M. Online discussion, student engagement, and criticalthinking. J Political Sci Educ. 2011;7(2):143–62.

3. Korobova N, Starobin SS. A comparative study of student engagement,satisfaction, and academic success among international and Americanstudents. J Int Stud. 2015;5(1):72–85.

4. Yin H. What motivates Chinese undergraduates to engage in learning?Insights from a psychological approach to student engagement research.High Educ. 2018;76(5):827–47.

5. Kuh GD. What we’re learning about student engagement from NSSE:benchmarks for effective educational practices. Change. 2003;35(2):24–32.

6. Fredricks JA, Blumenfeld PC, Paris AH. School engagement: potential of theconcept, state of the evidence. Rev Educ Res. 2004;74(1):59–109.

7. Finn JD, Zimmer KS. Student engagement: What is it? Why does it matter ?.Handbook of research on student engagement. New York: Springer; 2012.p. 97–131.

8. Long P, Barlow C, Lancastle S. A study into postgraduate medical studentsengagement with virtual learning enviornments for traning in emergencymedicine. United Kingdom: International Conference on InformationCommunication Technologies in Education; 2012.

9. Oza SK, Wamsley M, Boscardin CK, Batt J, Hauer KE. Medical students'engagement in interprofessional collaborative communication during aninterprofessional observed structured clinical examination: a qualitativestudy. J Interprof Educ Pract. 2017;7:21–7.

10. Reid HJ, Thomson C, McGlade KJ. Content and discontent: a qualitativeexploration of obstacles to elearning engagement in medical students. BMCMed Educ. 2016;16(1):188.

11. Pizzimenti MA, Axelson RD. Assessing student engagement and self-regulated learning in a medical gross anatomy course. Anat Sci Educ. 2015;8(2):104–10.

12. Gaebler C, Lehmann LS. Fostering student engagement in medicalhumanities courses. Virtual Mentor Vm. 2014;16(8):595–8.

13. Javadi A, Mohammadi Y, Akbari N. The condition of learning styles, studentengagement and its relationship with academic progress in BirjandUniversity of Medical Sciences. Future Med Educ J. 2017;7(2):23–8.

14. Sobocan M, Klemenc-Ketis Z. Medical students’ attitudes towards the use ofvirtual patients. J Comput Assist Learn. 2017;33(4):393–402.

15. Alelq AH. Simulation-based medical teaching and learning. J Fam CommuMed. 2010;17(1):35–40.

16. Sook Y, Roh IK, et al. Survey of factors influencing learner engagement withsimulation debriefing among nursing students. Nurs Health Sci. 2017;19:485–91.

17. Mayfield CH, Ohara PT, O'Sullivan PS. Perceptions of a mobile technologyon learning strategies in the anatomy laboratory. Anat Sci Educ. 2013;6(2):81–9.

18. Murray K. The Effects of Supplemental Online Learning Aids on StudentPerformance and Student Engagement in Medical Microbiology.M.A.Theses.Milwaukee: University of Wisconsin-Milwaukee; 2014.

19. Kim KJ, Hwang JY. Ubiquitous testing using tablets: its impact on medicalstudent perceptions of and engagement in learning. Korean J Med Educ.2016;28(1):57.

20. McCarthy D, O'Gorman C, Gormley G. Intersecting virtual patients andmicrobiology: fostering a culture of learning. Ulster Med J. 2015;84(3):173–8.

21. Stevens NT, McDermott H, Boland F, Pawlikowska T, Humphreys H. Acomparative study: do “clickers” increase student engagement inmultidisciplinary clinical microbiology teaching ? BMC Med Educ. 2017;17(1):70.


https://doi.org/10.1186/s12909-021-02858-7

https://doi.org/10.1186/s12909-021-02858-7

22. Smith M, Warland J, Smith C. An innovative strategy in evaluation: using astudent engagement framework to evaluate a role-based simulation. J NursEduc. 2012;51(3):151–4.

23. Nanji KC, Baca K, Raemer DB. The effect of an olfactory and visual cue onrealism and engagement in a health care simulation experience. SimulHealthc. 2013;8(3):143–7.

24. Kahu ER. Framing student engagement in higher education. Stud HighEduc. 2013;38(5):758–73.

25. Yin HB. Research path and transformation of college student engagement.Higher Educ Res. 2016;11:74–80.

26. Palinkas LA, Horwitz SM, Green CA, et al. Purposeful sampling for qualitativedata collection and analysis in mixed method implementation research.Admin Pol Ment Health. 2013;42(5).

27. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol.2006;3:77–101.

28. Undergraduate student engagement at a Chinese university: a case study.Educational Assessment Evaluation & Accountability, 2015, 27(2):1–23.

29. Paulhus DL, Duncan JH, Yik MSM. Patterns of shyness in east-Asian andEuropean-heritage students. J Res Pers. 2002;36(5):442–62.

30. Zhang XD, Liu YM, Hesheng O. Introduction to Psychology. Beijing: SciencePress; 2009. p. 116–7.

31. Duan JJ. Network deep learning from the perspective of learning science,vol. 112. Beijing: Science Press; 2018.

32. Chaffey LJ, Leeuw EJJ, Finnigan GA. Facilitating Students' reflective practicein a medical course: literature review. Educ Health Change Learn Prac. 2011;25(3):198–203.

33. Ulrich DL, Gillespie GL, Boesch MC, Bateman KM, Grubb PL. Reflectiveresponses following a role-play simulation of nurse bullying. Nurs EducPerspect. 2017;38(4):203–5.

34. Lewis AD, Huebner ES, Reschly AL, et al. The incremental validity of positiveemotions in predicting school functioning. J Psychoeduc Assess. 2009;27(5):397–408.

35. Cherry MG, Fletcher I, O'Sullivan H, et al. Emotional intelligence in medicaleducation: a critical review. Med Educ. 2014;48(5):468–78.

36. Okuda Y, Bond W, Bonfante G, et al. National Growth in simulation trainingwithin emergency medicine residency programs, 2003-2008. Acad EmergMed. 2008;15(11):1113–6.

37. Jennifer G, Ashish V, Richard H. Simulation provides deep learningopportunities for medical students intercalating in the biosciences. BMJ Stel,2018;0:1–2. DOI:https://doi.org/10.1136/bmjstel-2018-000318.

38. Eismann H, Palmaers T, Tsvetanov S, Hagemann V, Flentje M. Changes ofcollective orientation through a medical student’s anaesthesia simulationcourse – simulation-based training study with non-technical skills debriefingversus medical debriefing. BMC Med Educ. 2019;19:337.

39. Behrens C, Dolmans DHJM, Leppink J, et al. Ward round simulation in finalyear medical students: does it promote students learning? Med Teach. 2017;40(2):1–6. https://doi.org/10.1080/0142159X.2017.1397616.

40. Mcarthur P, Burch L, Moore K, Hodges MS. Novel active learningexperiences for students to identify barriers to independent living forpeople with disabilities. Rehabil Nurs. 2015;41(4):202–6.

41. Scott R, Simon F, Hugh B, Birch I. A BEME systematic review of the effects ofinterprofessional education: BEME Guide No. 39. Med Teach. 2016:1–13.https://doi.org/10.3109/0142159X.2016.1173663.

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