All 24 participants were third year medical students. Demographic data is available in Table 3.

Quantitative analysis

Means and standard deviations of self-report scores are presented in Table 4. Paired-samples t-tests were conducted to compare pre- to post-training scores on the self-report measures. Stoic ideation increased after training, t (21) = 3.009, p = 0.007, d = 0.641; as did Resilience, t (23) = 2.469, p = 0.021, d = 0.504; and Empathy, t (23) = 4.848, p < 0.001, d = 0.990. A post-hoc G* Power Analysis [50] revealed a power of 0.905.

Table 4 Means and standard deviations (in parentheses) for self-report measures pre-training, post-training and mean change in score

Correlational analyses of the change in self-report measures were conducted, finding a significant positive correlation between BRS score change and JSE score change, r (24) = 0.480, p = 0.018, 95% CI 0.071, 0.751], suggesting that as resilience increases so does empathy. There was no significant correlation between SABS score change and BRS score change r (22) = 0.282, p = 0.204, 95% CI [−0.167,0.634]; or JSE score change, r (22) = 0.240, p = 0.282, 95% CI [− 0.208,0.605], suggesting no relationship between Stoic ideation change and resilience or empathy change. A post-hoc G*Power Analysis [50] revealed a power of 0.687.

Qualitative analysis

Analysis generated four themes: 1. Negative visualisation aids emotional and practical preparedness; 2. Stoic mindfulness encourages students to think about how they think and feel; 3. Stoic reflection develops the empathic imagination; and 4. Accessibility of SeRenE.

Student quotes are labelled using participant and interview numbers.

Negative visualisation aids emotional and practical preparedness

When discussing their experiences of SeRenE, students stressed the utility of the exercises which facilitated negative visualisation (Exercises 1 and 3). This sort of reflection helped students to consider what might go wrong in a variety of situations and, in doing so, they were able to generate contingency plans to deal with outcomes different than what they hoped or expected. This was an element of the training that had impact at 2 months.

“One of the questions was asking about what am I going to do, and what could go wrong and how would I deal with it. So I do plan now, and I do think about how to … what to do and how to restructure things when stuff can’t happen at the right time or stuff like that.”

Student 15, Interview 2

Thinking in this way improved student confidence in clinical situations, as the fear of something going wrong was lessened.

“With the wards sometimes I feel anxious not knowing many people and still being quite new…but if I step back before I walk on and just sort of plan in my head what I want to do and what I would do if that doesn’t work out, I feel less uncertain and also less worried about saying the wrong thing or doing the wrong thing. That sort of thought process gives me confidence.”

Student 23, Interview 2

Though some may assume that negative visualisation would promote pessimism, students felt such exercises decreased the chance of them catastrophising when things did go wrong. Further, students identified negative visualisation as a more positive and proactive approach to reflection than models of reflection they had previously experienced. By thinking of, and orientating oneself to, solutions, students felt able to focus on problem-solving, as opposed to ruminating on what had happened.

“I feel like it’s allowed myself to sort of think about a more positive or beneficial way of things going … that’s what I particularly liked about the whole process.”

Student 12, Interview 1

The emotional preparedness negative visualisation fostered was perceived by students as increasing personal resilience by reducing stress and promoting adaptability in the face of change.

“It gives you more resilience because you can anticipate stuff going wrong. You can prepare yourself … and also give yourself some time to think about what’s already happened,”

Student 16, Interview 1

Additionally, students felt their productivity, both on and off the wards, increased as a result of practicing negative visualisation. In thinking about what could go wrong, students more readily had backup or contingency plans which acted as a sort of practical preparedness.

“When I’ve been at work in the hospital if something has gone wrong, because I’ve already thought through what might happen to myself when I start out on that task, if something does happen then I can just change my approach and what I’m doing really quickly … which is more efficient.”

Student 22, Interview 2

Stoic mindfulness encourages students to think about how they think and feel

It was evident that engaging in a Stoic sort of mindfulness encouraged students to reflect on their own emotions and responses to different situations. This was achieved, at least in part, by focusing attention on the present day, and what was happening around students in the ‘daily reflection’ exercise.

“I think it’s helped because I’ve never had any exercises where I had to reflect on my day and I think it’s helped in terms of me sort of understanding my feelings and why I feel a certain way.”

Student 3, Interview 1

Alongside an increased awareness of their own emotional state, SeRenE also facilitated consideration, within some students, of how they were thinking. In technical terms, Stoic mindfulness promoted metacognition.

“I was quite surprised actually that it did make me think differently. After a couple of days I did sort of … I was taking note more of my thought processes and my actions and how I was viewing things … I was like, “okay today I need to think in a certain way.” So that … was a really positive thing … it’s made me change the way I think about situations.”

Student 12, Interview 1

Such metacognition helped some students to challenge what they thought, and several students voiced thinking differently about situations that had previously made them angry or upset because of their engagement in SeRenE.

“It’s actually realising when you are having judgments, like actually recording throughout the day and then realising it’s not a situation you can control, but you can control your responses. That was brilliant. Definitely very useful.”

Student 19, Interview 1

Other students voiced that an increased awareness of their emotional state, thought processes and achievements helped them to recognise when they were being overly pejorative with themselves and fostered a kindness towards themselves.

“The last section that was like … what did you do well, what didn’t you do well, I think that was quite useful to sort of say, well I’ve done well today. I don’t have to completely beat myself up about it, it’s not all gone wrong”.

Student 7, Interview 1

Some students admitted to continuing to use SeRenE training formally and within written reflections 2 months after the training was completed in their follow up interviews. For others, the changes in thought processes and practices were more subconscious.

“Subconsciously I do reflect more. I haven’t done as much formally like writing it down I did during the training but definitely I catch myself more doing it at the end of the day right before bed.”

Student 3, Interview 2

Stoic reflection develops the empathic imagination

Within SeRenE, exercises which promoted Stoic reflection (exercises 3 and 4) promoted a more empathic approach to patients and clinical care. Students found that reflecting on patient cases and what could go wrong helped them to consider the patient perspective.

“It helped me look at things from the patient’s point of view … I think it will help me understand patients a bit better as I now put myself in their shoes more.”

Student 3, Interview 1

Considering why a situation involving empathy could escalate or derail helped students to consider patient context and, interestingly, socioeconomic determinants of health that may be at play within a consultation.

“It has been interesting to think about what could go wrong because sometimes I’m thinking “Well, what’s happening with this person at home?”. Is there something going on in the home like a relationship breakdown or is someone they love suffering. And that thought process gives me more empathy for them, because you never really know how hard someone’s life might be and how that might make them angry or lash out with behaviours like drug use.”

Student 24, Interview 2

In addition, students felt more able to put themselves in their patient’s shoes as a result of engaging in reflection regarding empathy. This seemed borne of a sensitivity to students’ own judgements and feelings- with this sensitivity came an appreciation for others’ feelings and judgments, too.

“Evaluating our own judgement and our own feelings towards things can be helpful to like remind us when we’re in a clinical setting to take into account the kind of things that patients may be judging and feeling themselves. So in that case it helped with putting yourself in their kind of shoes.”

Student 2, Interview 1

Some students felt able to mobilise these empathic insights to make changes to their practice …

“The patient scenario, it does make me think twice about what I say and do and what my body language is showing to the patient because that will definitely influence the consultation”.

Student 4, Interview 1

… but for others, not knowing how to change their practice in regard to these new insights generated uncertainty. There were suggestions that SeRenE could be incorporated into communication skills training, where students could reflect on these insights as a group and work with tutors to amass new skills for situations they had identified as potentially troublesome.

“ … with the patient thing, the last question I think was how would you cope with what went wrong? I think maybe because of the way I think, I feel like I was giving the same answer every day … I would maybe need contact with mentors to get more practice on how I would better myself for the future if a similar consultation happened.”

Student 8, Interview 1

Accessibility of SeRenE

The final theme within our data concerns the accessibility of SeRenE – what worked in practice, and what did not.

The training was felt to be easy to use.

“It was really simple to use and easy log-in and it was really helpful to have the hints.”

Student 10, Interview 1

The most commonly voiced difficulty in regard to the accessibility of SeRenE concerned exercise 2, ‘Evaluating Judgments’. Several students misunderstood what was meant by the term ‘judgments’, taking it to instead mean ‘judgmental’, which hampered engagement.

“I guess it’s just the kind of person I am, but I don’t usually judge people”

Student 4, Interview 1

Several students noted the utility of the examples provided on the first day of training and would have liked to have been able to access these worked examples every day. For some students, particularly those who did not volunteer during Covid, patient cases were difficult to think of within exercise 3, and so additional examples to prompt reflection were desired.

“I found it difficult to think of a different clinical scenario each day … because we’re not on clinical placement at the moment.”

Student 20, Interview 1

There was discussion within students’ follow up interviews regarding the necessary length of SeRenE, and the need for repetition over time. Whilst, generally, students felt the initial training was of appropriate length, there was disagreement regarding whether it would be beneficial to repeat training during an academic year and, if so, how frequently. What became apparent was that student preferences differed, and a flexible approach following initial training, where students can reengage at their own leisure, may serve the needs of more students than a mandated approach. Though the training platform was well received, having to access SeRenE through a web browser was off-putting for some. Student preference seemed to be for an app that could be accessed on-the-go.

“I really loved how it was spread out over 2 weeks because it actually meant you had a lot of time to process it and then you could think from one day onto the next.”

Student 6, Interview 1

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