Physiological and self-assessed psychological stress induced by a high fidelity simulation course among third year anesthesia and critical care residents: An observational study

Impact of prebriefing on emotions in a high-fidelity simulation session: A randomized controlled study

INTRODUCTION

Medical simulation is associated with intense emotions which influence human behavior. We aim to investigate how prebriefing impacts on learners' emotions during a high-fidelity simulation (HFS) session.

METHODS

This is a prospective randomized controlled study. Participants were randomly allocated to receive a standardized prebriefing (SP group) versus not receiving it (NSP group). Debriefing following the «good judgment» approach, structured in reactions, understanding and summary phases, was used in both groups. In order to assess emotions, we used the circumplex model of affect applying the Affect Grid scale, which was performed prior to prebriefing, following case performance and following debriefing. Debriefing times were also assessed.

RESULTS

A total of 128 physicians participate in the study (64 vs. 64). Following case performance, this HFS session was experienced with significantly more pleasant emotions compared to baseline, that were maintained during debriefing (p < 0.01) while alertness increased after case performance diminishing after debriefing (p < 0.01). There were no statistical significant differences between groups. In the NSP group, total debriefing (p = 0.003) and understanding phase (p = 0.002) times were significantly longer.

CONCLUSIONS

This HFS session was experienced as pleasant with high alertness with no specific emotional impact attributable to prebriefing. Prebriefing leads to a freer flowing debriefing.

A scoping review of emotions and related constructs in simulation-based education research articles

BACKGROUND

While acknowledgement of emotions' importance in simulation-based education is emerging, there are concerns regarding how education researchers understand the concept of emotions for them to deliberately incorporate emotionally charged scenarios into simulation-based education. This concern is highlighted especially in the context of medical education often lacking strong theoretical integration. To map out how current simulation-based education literature conceptualises emotion, we conducted a scoping review on how emotions and closely related constructs (e.g. stress, and emotional intelligence) are conceptualised in simulation-based education articles that feature medical students, residents, and fellows.

METHODS

The scoping review was based on articles published in the last decade identified through database searches (EMBASE and Medline) and hand-searched articles. Data extraction included the constructs featured in the articles, their definitions, instruments used, and the types of emotions captured. Only empirical articles were included (e.g. no review or opinion articles). Data were charted via descriptive analyses.

RESULTS

A total of 141 articles were reviewed. Stress was featured in 88 of the articles, while emotions and emotional intelligence were highlighted in 45 and 34 articles respectively. Conceptualisations of emotions lacked integration of theory. Measurements of emotions mostly relied on self-reports while stress was often measured via physiological and self-report measurements. Negative emotions such as anxiety were sometimes seen as interchangeable with the term stress. No inferences were made about specific emotions of participants from their emotional intelligence.

CONCLUSIONS

Our scoping review illustrates that learners in simulation-based education are most often anxious and fearful. However, this is partially due to medical education prioritising measuring negative emotions. Further theoretical integration when examining emotions and stress may help broaden the scope towards other kinds of emotions and better conceptualisations of their impact. We call for simulation education researchers to reflect on how they understand emotions, and whether their understanding may neglect any specific aspect of affective experiences their simulation participants may have.

A scoping review of self-monitoring in graduate medical education

BACKGROUND

Physicians and physicians-in-training have repeatedly demonstrated poor accuracy of global self-assessments, which are assessments removed from the context of a specific task, regardless of any intervention. Self-monitoring, an in-the-moment self-awareness of one's performance, offers a promising alternative to global self-assessment. The purpose of this scoping review is to better understand the state of self-monitoring in graduate medical education.

METHODS

We performed a scoping review following Arksey and O'Malley's six steps: identifying a research question, identifying relevant studies, selecting included studies, charting the data, collating and summarising the results and consulting experts. Our search queried Ovid Medline, Web of Science, PsychINFO, Eric and EMBASE databases from 1 January 1999 to 12 October 2022.

RESULTS

The literature search yielded 5363 unique articles. The authors identified 77 articles for inclusion. The search process helped create a framework to identify self-monitoring based on time and context dependence. More than 20 different terms were used to describe self-monitoring, and only 13 studies (17%) provided a definition for the equivalent term. Most research focused on post-performance self-judgements of a procedural skill (n = 31, 42%). Regardless of task, studies focused on self-judgement (n = 66, 86%) and measured the accuracy or impact on performance of self-monitoring (n = 41, 71%). Most self-monitoring was conducted post-task (n = 65, 84%).

CONCLUSION

Self-monitoring is a time- and context-dependent phenomenon that seems promising as a research focus to improve clinical performance of trainees in graduate medical education and beyond. The landscape of current literature on self-monitoring is sparse and heterogeneous, suffering from a lack of theoretical underpinning, inconsistent terminology and insufficiently clear definitions.

Biological testing during acute psychological stress: A hindrance or an opportunity?

All humans deal with acute psychological stress periodically. Some individuals are affected by needle phobia in which a heightened sense of arousal is precipitated by venepuncture. Acute psychological stress invokes a range of physiological changes including activation of the sympathetic-adrenal-medullary and hypothalamic-pituitary-adrenal axes. In this review article, we first examine the human response to acute stress. We then provide an overview of how psychological stress in a subject is likely to be a source of pre-analytical variability for certain measurands, and the major biochemical markers that have been studied in research aiming to quantify stress. As such, we highlight how stress can be a hindrance to the accurate interpretation of certain laboratory results (particularly cortisol, prolactin, metanephrines and growth hormone), and point out the role that biochemical analysis might play in future studies looking at the effects of stress on human behaviour.

Stress responses in high-fidelity simulation and standard simulation training among medical students

BACKGROUND

Simulation has been recognized as a shift in healthcare education that can improve skills and patient safety and outcomes. High-fidelity simulation of critical medical situations can be a source of stress among participants that can interfere with students' abilities leading to unexpected emotional responses. The aim of this study is to determine if two simulation methods, high-fidelity (HF) and procedural simulation (PS), may be associated with stress responses at a self-perceived and biological level (salivary cortisol variations), and to compare stress levels of the two different simulation method. We also wanted to find independent variables associated with cortisol total hormonal output.

METHODS

A quasi-experimental before-after study was used including the administration of questionnaires, and biomarkers evaluation by salivary cortisol samples before and after simulation. A total of 148 students were eligible and agreed to participate in the study. We used paired T-test for mean comparison regarding State-trait anxiety for both HF and PT simulations. For NASA-TLX we performed a T-test mean comparison between groups. We used paired T-test mean comparison for cortisol analysis. Multivariable linear regression has been used to assess variables associated with AUC_g values and perceived stress.

RESULTS

values of STAI-Y scores were relatively higher at the end of the HF and PS sessions. NASA-TLX was significantly higher at baseline for the HF simulations, with respect to the PS simulation. Cortisol fold increase was significantly different in the two groups. Linear regression showed that cortisol AUCg was related to the STAI-Y score in both groups.

CONCLUSION

Participating students developed a stress response both after in the HF and PS training, testified by psychological and biological outputs. According to our results, stress levels were increased for simply being in a simulation scenario than to the intrinsic complexity of the task required. More studies are needed to confirm this trend and to clarify the role of simulated stress response in a long-term learning scenario.

Stress responses in high-fidelity simulation among anesthesiology students

Simulation sessions can produce high-fidelity emergency situations that facilitate the learning process. These sessions may also generate a complex stress response in the learners. This prospective observational study assessed psychological, physiological, immunological, and humoral levels of stress during high-fidelity simulation training. Fifty-six undergraduate medicine students who took part in a medical simulation session were assigned team roles (physician, nurse or assistant). Subsequently, each participant was assessed before the scenario (T₀), after the procedure (T₁), and two hours later (T₂). Psychological stress and anxiety were measured at T₀ and T₁, using the State-Trait Anxiety Inventory (STAI) and Dundee Stress State Questionnaire (DSSQ). Cortisol, testosterone, secretory immunoglobulin class A (sIgA), alpha-amylase, and oxygen saturation level were measured at T₀, T₁, and T₂, as was the physiological response indicated by heart rate (HR) and blood pressure (BP). It was found that the onset of task performance was related to increased anticipatory worry and higher oxygen saturation. The participants reported decreased worry, followed by increased emotional distress after the simulation training (T₁). Participants trait anxiety predicted the intensity of worry, distress and task engagement. In contrast, no clear relationships were found between trait anxiety and biological stress markers. Testosterone levels were growing significantly in each phase of measurement, while physiological responses (BP, HR) increased at T₁ and declined at T₂. The levels of stress markers varied depending on the assigned roles; however, the trajectories of responses were similar among all team members. No evidence for prolonged cortisol response (T₁, T₂) was found based on psychological stress at the onset of simulation (T₀). Regression analysis followed by receiver operating characteristics analyses showed uncertain evidence that initial state anxiety and worry predicted the levels of sIgA. Medical students are relatively resilient in terms of stress responses to medical simulation. The observed stress patterns and interrelationships between its psychological, physiological, hormonal, and immunological markers are discussed in accordance with theoretical concepts, previous research work, and further recommendations.

Effect of high-fidelity simulation on alpha-amylase activity and concentrations of secretory immunoglobulin class A, cortisol, and testosterone among medical students

PURPOSE

High-fidelity simulation calls heavily upon cognitive capacities and generates stress and anxiety. The objective of this prospective, observational study was to evaluate the degree of stress in medical students by measuring hormone levels during critical care classes.

METHODS

Overall, 55 students (senior years of medical faculty) of both sexes were divided into 5-person teams. Demographic data and information on diagnosed diseases, stimulants used, and previous experience in the field of medical simulation were collected with a personal questionnaire. Before starting the scenario (T0), after the end of the scenario (T1), and 120 min thereafter (T2), stress level was measured. For this purpose, systolic blood pressure, diastolic blood pressure, mean blood pressure, heart rate and blood oxygen saturation were evaluated. In addition, saliva was collected to determine alpha-amylase activity and the concentrations of secretory immunoglobulin class A, cortisol, and testosterone.

RESULTS

Among hemodynamic parameters, systolic and mean blood pressure and heart rate were significantly higher in T1 than in T0 and T2 time points (p < 0.05). Cortisol concentration was higher at T2 compared with T0 and T1. Alpha-amylase activity was highest at T1. Secretory immunoglobulin class A concentration was highest at T0, followed by T1 and then T2. These differences were not statistically significant. Testosterone concentration showed significantly higher values at T2 compared with T0 and T1 (p < 0.05). The analysis of team leaders vs. other members revealed significantly lower cortisol and alpha-amylase values in leaders (p < 0.05).

CONCLUSIONS

High-fidelity simulation is a useful education method in medical subjects, especially in cases where a mistake could produce serious or irreversible consequences. It can increase stress hormone concentrations and thus can be assumed effective as a learning aid even in senior-year students of medical faculty.

Stress level experienced by participants in realistic simulation: a systematic review

OBJECTIVES

to identify the available evidence regarding stress levels experienced by participants in education based on a realistic simulation.

METHODS

systematic review that included randomized clinic trials on electronic databases: Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, Latin-American and Caribbean Literature in Health Sciences, LIVIVO, PubMed, Scopus, and Web of Science. The additional search was performed on Google Scholar and OpenGrey. All searches occurred on September 24, 2020. The methodologic quality of the results was evaluated by the Cochrane Collaboration Risk of Bias Tool.

RESULTS

eighteen studies were included, which evaluated the participants' stress using physiologic, self-reported measures, or the combination of both. Stress as experienced in a high level in simulated scenarios.

CONCLUSIONS

evidence of the study included in this systematic review suggest that stress is experienced in a high level in simulated scenarios.

Does prior exposure to clinical critical events influence stress reactions to simulation session in nursing students: A case-control study

BACKGROUND

Simulation is a pedagogical method known to be a generator of stress, that could be influenced by previous stressful experiences.

OBJECTIVES

The purpose of this study was to determine the impact of previous experience with a clinical critical event on the stress experienced by nursing students during simulation session of critical events, and on the stress experienced during clinical critical events subsequent to the training.

DESIGN

Observational case-control study.

SETTINGS

Four critical event scenarios were created using full-scale simulation.

PARTICIPANTS

Two hundred and fifteen undergraduate nursing students of semester four. The control group (n = 112) consisted of learners who had not previously experienced a critical event. The prior exposure group (n = 103) consisted of learners who had experienced a critical event prior to the course.

METHODS

Stress levels were assessed using the self-report stress numerical rating scale-11.

RESULTS

There was no significant difference in the level of stress between the prior exposure group and the control group before, during or expected after the simulation session. A significant decrease in stress was observed in both groups from before the course to during the session (p < 0.05) and expected after the session (p < 0.05). There was no significant difference between the expected post-session stress level and the stress levels reported four months after the training (p = 0.966). At four months, there was no significant difference in stress levels between the groups (p = 0.212).

CONCLUSIONS

The prior experience of a clinical critical event before a simulation course did not influence their reported stress level during the simulation session. Conversely, simulation-based training of critical situations appears to reduce the level of self-assessed stress during critical events in clinical practice after the training.

High-Fidelity simulation-based program improves flow state scale in the perinatal team

Background

We aimed to evaluate the degree of realism and involvement, stress management and awareness of performance improvement in practitioners taking part in high fidelity simulation (HFS) training program for delivery room (DR) management, by means of a self-report test such as flow state scale (FSS).

Methods

This is an observational pretest-test study. Between March 2016 and May 2019, fourty-three practitioners (physicians, midwives, nurses) grouped in multidisciplinary teams were admitted to our training High Fidelity Simulation center. In a time-period of 1 month, practitioners attended two HFS courses (model 1, 2) focusing on DR management and resuscitation maneuvers. FSS test was administred at the end of M1 and M2 course, respectively.

Results

FSS scale items such as unambiguous feed-back, loss of self consciousness and loss of time reality, merging of action and awareness significantly improved (P < 0.05, for all) between M1 and M2.

Conclusions

The present results showing the high level of practitioner involvement during DR management-based HFS courses support the usefulness of HFS as a trustworthy tool for improving the awareness of practitioner performances and feed-back. The data open the way to the usefulness of FSS as a trustworthy tool for the evaluation of the efficacy of training programs in a multidisciplinary team.

Benefits of simulation using standardized patients for training dermatology residents in breaking bad news

INTRODUCTION

Simulation in healthcare is a rapidly developing teaching method in the training of technical procedures. It is also used to enable caregivers to learn how to inform patients of serious illness and complex health status. However, its use is not widespread in the field of dermatology. This study investigated the utility of simulation as regards disclosing melanoma diagnosis, taking resident physician satisfaction as a primary endpoint.

MATERIALS AND METHODS

Fifteen dermatology residents were recruited as trainees. Four scenarios were allocated based on length of residency. An introductory briefing was held prior to the training sessions. Debriefing took place on completion of the diagnosis disclosure consultation. The participants completed questionnaires after the simulation session, after debriefing, and 3 months after the simulation session. The primary endpoint was usefulness of the session felt by trainees several months after the simulation.

RESULTS

The majority of participants (93.3%) thought the session helped with stress management, improved their attitude and control over their reaction (86.6%), and improved their communication skills (100%). They rated the usefulness of the simulation at 7.79/10 on average (range: 5-10).

DISCUSSION

According to our findings the resident physicians involved, particularly those with the least experience, were satisfied with this type of learning technique. Any difficulties encountered by these residents were brought to light and addressed during debriefing.

CONCLUSION

There would appear to be real benefits to be reaped from simulation, whatever the stage of medical training at which it takes place. Simulation should become an increasingly important part of contemporary pregraduate specialty programs.

Psychophysiological Stress Indicators of Heart Rate Variability and Electrodermal Activity With Application in Healthcare Simulation Research

STATEMENT

Psychological stress arises from a stressor placed on an individual that leads to both emotional and physiological responses. The latter is referred to as psychophysiological stress. Healthcare simulation provides a platform to investigate stress psychobiology and its effects on learning and performance. However, psychophysiological stress measures may be underused in healthcare simulation research. The inclusion of such measures with subjective measures of stress in healthcare simulation research provides a more complete picture of the stress response, thereby furthering the understanding of stress and its impact on learning and performance. The goals of this article were to review 2 commonly used psychophysiological stress measures involving heart rate variability and electrodermal activity reflecting sweat gland activity and to demonstrate their utility in an example pilot study in healthcare simulation research.

Does stress influence the performance of cardiopulmonary resuscitation? A narrative review of the literature

Cardiopulmonary resuscitation represents a major physical and psychological challenge for all involved health care workers because survival of the patients is closely related to the timely and accurate actions of rescuers. Consequently, rescuers may experience high levels of acute mental stress. Stress, in turn, may influence attentional resources and distractibility, which may affect the quality of resuscitation. This narrative review summarizes the current state of research concerning the influence of stress on resuscitation performance. Peer-reviewed studies retrieved in scientific databases were eligible. We found that rescuers experience high levels of stress and some associations of higher levels of stress with lower resuscitation performance. Finally, few interventional studies assessed whether interventions aiming at reducing levels of stress may have a beneficial effect on resuscitation performance, but results are variable. Although the mechanisms linking stress to performance of emergency teams are still not fully understood, factors such as individual experience and self-confidence of rescuers, gender composition and hierarchy within resuscitation teams may play an important role. This review provides a targeted overview of how stress can be defined and measured, how it may influence emergency situations such as a cardiopulmonary resuscitation, and which interventions have the potential to reduce overwhelming stress.

Evaluation of resident satisfaction and change in knowledge following use of high-fidelity simulation teaching for anaesthesia residents

Background and Aims:

Anaesthesia practice demands medical knowledge and skills as essential components for patient management in peri-operative emergencies. Since all residents are not exposed to such situations during their residency, training them using simulation technology could bridge this knowledge and skill gap. The aim of this study was to train and evaluate residents to manage anaesthesia emergencies on high fidelity simulators.

Methods:

Kirkpatrick model of program evaluation was carried out. Resident reaction was captured using a satisfaction questionnaire and the change in knowledge was assessed using pre-test and post-test Multiple Choice Questions (MCQs). Six scenarios were created and executed on a human patient simulator (HPS). All 22 residents participated in this teaching learning method. The steps of simulation teaching included pre-test, pre-briefing, orientation to manikins, performing/scribe, debriefing, feedback questionnaire, and post-test. The satisfaction questionnaire was administered following the second and fourth scenario.

Results:

95% residents agreed on overall satisfaction, that it helps in building team dynamics and clinical reasoning. All students agreed that this teaching had positive professional impact. 14% residents felt they were anxious during the class. The items in the questionnaire had a Cronbach's α value of 0.9. The mean score for pre-test was 24.22 ± 7 (Mean ± SD) and the post-test was 47.18 ± 5.6, the difference between the scores were statistically significant (P = 0.007).

Conclusion:

The use of high-fidelity simulation to train anaesthesia residents resulted in greater satisfaction scores and improved the residents' reasoning skills.

Development and Evaluation of a Virtual Research Environment to Improve Quality of Care in Overcrowded Emergency Departments: Observational Study

BACKGROUND

Despite a wide range of literature on emergency department (ED) overcrowding, scientific knowledge on emergency physicians' cognitive processes coping with overcrowding is limited.

OBJECTIVE

This study aimed to develop and evaluate a virtual research environment that will allow us to study the effect of physicians' strategies and behaviors on quality of care in the context of ED overcrowding.

METHODS

A simulation-based observational study was conducted over two stages: the development of a simulation model and its evaluation. A research environment in emergency medicine combining virtual reality and simulated patients was designed and developed. Afterwards, 12 emergency physicians took part in simulation scenarios and had to manage 13 patients during a 2-hour period. The study outcome was the authenticity of the environment through realism, consistency, and mastering. The realism was the resemblance perceived by the participants between virtual and real ED. The consistency of the scenario and the participants' mastering of the environment was expected for 90% (12/13) of the participants.

RESULTS

The virtual ED was considered realistic with no significant difference from the real world with respect to facilities and resources, except for the length of time of procedures that was perceived to be shorter. A total of 100% (13/13) of participants deemed that patient information, decision making, and managing patient flow were similar to real clinical practice. The virtual environment was well-mastered by all participants over the course of the scenarios.

CONCLUSIONS

The new simulation tool, Virtual Research Environment in Emergency Medicine, has been successfully designed and developed. It has been assessed as perfectly authentic by emergency physicians compared with real EDs and thus offers another way to study human factors, quality of care, and patient safety in the context of ED overcrowding.