Table 2.

Themes and subthemes identified in written free-text responses and focus groups, (n=97)

Theme	Subtheme	Examples
Learning in the simulated environment	Practical clinical learning	It’s great to be able to have an environment where we can make some mistakes at this stage of our learning, without any kind of critical consequences. And then really get a good learning experience from those mistakes. Not everything has to go right.
	Retention of knowledge	…being able to participate in a simulation creates a better learning environment that sticks, rather than just reading.
Teaching in the simulated environment	Challenges of case selection	I think a lot of the times these cases were taken from what we've seen at hospitals, so it’s good to see what other teams have seen as well, and how they've managed compared with what you've been able to see, because we don't actually get to see a lot of the same things. I would prefer if you guys (faculty) already had 20 simulated cases already there and we choose which ones are interesting to us…. Rather than us just making up these random cases and trying to scramble as to what might be a good learning point for us to do.
	Learning about simulation teaching	You actually get to experience all the stages from writing up, to actually preparing on the day, briefing, and then debriefing. You go through different roles, and I think that’s a good thing to experience, especially as team work. One of the biggest problems that I had was finding out what is possibly an issue with the limitations of the device, versus this is how the patient is actually presenting.
	Experiencing patient perspective	You do get another perspective, though. Like voicing the patient, for instance, I kind of have a bit more of an idea of what it might be like for the patient, lying there in ED, in pain, and just having a group of people talking about you but not involving you in the conversation, being kind of… Like that kind of perspective that you don't get as the doctor.
	Appreciation of logistics of simulation teaching	I think the main thing that tripped our group up…. was when the people doing the sim kind of went off of what we we're meaning (them) to do and none of us knew what to do to get them back on the path. We didn't have any contingency plan…. How do we get them to check the blood pressure? How do we get them to realise they need call the blood bank?
Teaching peers and taking on an educator role	Learning in more depth through teaching	Designing a sim allowed me to gain an in-depth knowledge of the expected management protocol for our condition. It also helped me understand the potential pitfalls in managing such conditions. Useful for working out how labs/ vitals/ etc will present in different pathologies and recognising resources to guide management.
	Debriefing/providing feedback	I think the most valuable part of the peer sim is to debrief and actually getting familiar with the case yourself enough to talk about it in that much detail and actually know how to manage it. Sometimes you feel like you don't want to be too critical of your peers because you know how hard it is in the room when everything’s happening. Like when we were giving feedback, I definitely didn't want to come across like ’you guys sucked. What were you thinking?’ Because, it’s so hard and like we know it’s hard. But I think I agree it is really important to have that negative and positive feedback because otherwise we're not learning…. I felt like I had to consciously give myself permission to say things.
	Uncertainty in providing quality teaching	Have I studied this enough? Is this in enough depth? Do my colleagues find this relevant, interesting, useful? Like it’s hard to know if you're hitting the right points.
	Working with faculty	I really appreciated the iterative process with getting feedback from (faculty) and changing the scenario and lab results. The process made my clinical reasoning a lot stronger.
	Teaching peers	But, I definitely thought it was really fun to come up with this scenario but then also to talk to people afterwards and be like, this is kind of what we were going for and run through the debrief. I thought that doing all of that was really fun. I didn’t enjoy this aspect. I prefer to be the learner than the peer (teacher) for sims.
Learning from peers	Receiving feedback from peers	I found there was actually a significant advantage to have peer feedback, because it’s a lot easier for me, I think it’s a lot easier for a lot of people, to take criticism, to take critical feedback from a peer than it is from a consultant or registrar. But a student can say the same thing, and you (instructor) can say the same thing, what you have is you have this ability to make it very coherent and simple in a way that translates well to me as something I can learn from, and keep with.
	Peer learning through observation	I think it was useful to see or observe other students. Like we always see more senior clinicians all the time, managing a problem, taking care of it, and to see other people with our same level of training trying to work through it was a little reassuring in a way.
	Peer learning through competition	….they've set up something, can we get through this scenario and keep our patient intact, or have they beaten us? It’s maybe a little bit of fun if we think of it that way.
	Appropriateness of level of difficulty	I thought everyone would agree that (the peer scenarios were) really fair, that each student should have pretty good knowledge about it…. I thought the debriefs were really good to be by other students, because they kind of just hit the points that as a fourth year medical student it’s probably appropriate that this is what you already, what you actually know. Instead of just going too far above where you (are). I thought the thing written by students just ensured that it was pitched (appropriately), and I thought that it was.
Time and effort expended	Group work	The value of team work both in designing as well as participating in a case… The sims can only be as good as the effort the teams put into them. Some team members slacked a lot.
	Value of PAL-SBE relative to other activities	I thought that was really important, because I'm happy to put time into it, because I think it’s been really worthwhile…as far as the benefit gained, I think just doing and watching the scenarios is the most helpful. So I didn't notice it being hugely more beneficial that we or our classmates were running the sims today.
	Additional workload	I don't think the work was a concern at all. We shouldn't expect to not do any work at (medical) school anyway. It was difficult to find time on my already very busy rotation to write our scenario so it felt like the more in-depth aspects were missed.

ED, emergency department; PAL, peer-assisted learning; SBE, simulation-based education.