Endocrine and psychological stress responses in a simulated emergency situation

Exploring Immersive Multimodal Virtual Reality Training, Affective States, and Ecological Validity in Healthy Firefighters: Quasi-Experimental Study

BACKGROUND

Firefighters face stressful life-threatening events requiring fast decision-making. To better prepare for those situations, training is paramount, but errors in real-life training can be harmful. Virtual reality (VR) simulations provide the desired realism while enabling practice in a secure and controlled environment. Firefighters' affective states are also crucial as they are a higher-risk group.

OBJECTIVE

To assess the impact on affective states of 2 simulated immersive experiences in a sample of healthy firefighters (before, during, and after the simulation), we pursued a multivariate approach comprising cognitive performance, situational awareness, depression, anxiety, stress, number of previous adverse events experienced, posttraumatic stress disorder (PTSD) severity, and emotions. The efficacy and ecological validity of an innovative VR haptic system were also tested, exploring its impact on performance.

METHODS

In collaboration with the Portuguese National Fire Service School, we exposed 22 healthy firefighters to 2 immersive scenarios using the FLAIM Trainer VR system (neutral and arousing scenarios) while recording physiological data in a quasi-experimental study. Baseline cognitive performance, depression, anxiety, stress, number of adverse events, and severity of PTSD symptoms were evaluated. Positive and negative affective states were measured before, between, and after each scenario. Situational awareness, sense of presence, ecological validity, engagement, and negative effects resulting from VR immersion were tested.

RESULTS

Baseline positive affect score was high (mean 32.4, SD 7.2) and increased after the VR tasks (partial η2=0.52; Greenhouse-Geisser F1.82,32.78=19.73; P<.001). Contrarily, mean negative affect score remained low (range 11.0-11.9) throughout the study (partial η2=0.02; Greenhouse-Geisser F2.13,38.4=0.39; P=.69). Participants' feedback on the VR sense of presence was also positive, reporting a high sense of physical space (mean score 3.9, SD 0.8), ecological validity (mean score 3.8, SD 0.6), and engagement (mean score 3.8, SD 0.6). Engagement was related to the number of previously experienced adverse events (r=0.49; P=.02) and positive affect (after the last VR task; r=0.55; P=.02). Conversely, participants reported few negative effects (mean score 1.7, SD 0.6). The negative effects correlated positively with negative affect (after the last VR task; r=0.53; P=.03); and avoidance (r=0.73; P<.001), a PTSD symptom, controlling for relevant baseline variables. Performance related to situational awareness was positive (mean 46.4, SD 34.5), although no relation was found to metacognitively perceived situational awareness (r=-0.12; P=.59).

CONCLUSIONS

We show that VR is an effective alternative to in-person training as it was considered ecologically valid and engaging while promoting positive emotions, with few negative repercussions. This corroborates the use of VR to test firefighters' performance and situational awareness. Further research is needed to ascertain that firefighters with PTSD symptomatology are not negatively affected by VR. This study favors the use of VR training and provides new insights on its emotional and cognitive impact on the trainee.

Too stressed to think? A scoping review of the literature for healthcare educators utilising high acuity clinical scenarios

BACKGROUND

The practise of paramedicine can be highly stressful particularly where urgent lifesaving decisions need to be made. Traditionally, educators have adopted the approach of placing students in simulated stressful situations as a way of learning to cope with these challenges. It is unclear from the literature whether traditional stress inoculation enhances or hinders learning. This scoping review aims to identify and examine both the peer-reviewed and grey literature reporting physiological stress responses to high-acuity scenarios in paramedicine and cognate healthcare disciplines.

METHODS

Adhering strictly to JBI Evidence Synthesis Manual for conducting a scoping review, medical subject headings and areas, keywords and all other possible index terms were searched across EBSCOhost (Medline, CINAHL and APA PsycInfo), Scopus and, PubMed. English language articles both published (peer-reviewed academic papers, reports and conference proceedings) and unpublished (grey literature, Google Scholar reports) were included, and publications citing retrieved articles were also checked.

RESULTS

Searches performed across five electronic databases identified 52 articles where abstracts indicated potential inclusion. From this, 22 articles which reported physiological or psychophysiological responses to stressful scenario-based education were included.

CONCLUSION

This review identified that an acceptable level of stress during simulation can be beneficial, however a point can be exceeded where stress becomes a hinderance to learning resulting in underperformance. By identifying strategies to moderate the impact of acute stress, educators of paramedic and other healthcare students can utilise high-acuity clinical scenarios to their andragogical armamentarium which has the potential to improve real-world clinical outcomes.

A Wearable Electrochemical Sensor Based on a Molecularly Imprinted Polymer Integrated with a Copper Benzene-1,3,5-Tricarboxylate Metal-Organic Framework for the On-Body Monitoring of Cortisol in Sweat

Owing to their potential to transform traditional medical diagnostics and health monitoring, wearable biosensors have become an alternative evolutionary technology in the field of medical care. However, it is still necessary to overcome some key technique challenges, such as the selectivity, sensitivity, and stability of biometric identification. Herein, a novel, wearable electrochemical sensor based on a molecularly imprinted polymer (MIP) integrated with a copper benzene-1,3,5-tricarboxylate metal-organic framework (MOF) was designed for the detection of stress through the on-body monitoring of cortisol in sweat. The MOF was used as the substrate for MIP deposition to enhance the stability and sensitivity of the sensor. The sensor consisted of two layers, with a microfluidic layer as the top layer for spontaneous sweating and a modified electrode as the bottom layer for sensing. The sensor measured cortisol levels by detecting the current change that occurred when the target molecules bound to the imprinted cavities, using Prussian blue nanoparticles embedded in the MIP framework as the REDOX probe. The proposed sensor exhibited a linear detection range of 0.01-1000 nM with a detection limit of 0.0027 nM, and favorable specificity over other analogies. This facile anti-body free sensor showed excellent stability, and can be successfully applied for in situ cortisol monitoring.

Association between cortisol levels and performance in clinical simulation: a systematic review

OBJECTIVE

To identify how stress measured by salivary cortisol during clinical simulation-based education, or simulation and another teaching method, impacts performance.

METHOD

Systematic review of the association between cortisol and performance in simulations. The following databases were used: PubMed, LIVIVO, Scopus, EMBASE, Latin American and Caribbean Health Sciences Literature (LILACS) and Web of Science. Additional searches of gray literature were carried out on Google Scholar and Proquest. The searches took place on March 20, 2023. The risk of bias of randomized clinical trials was assessed using the Cochrane Collaboration Risk of Bias Tool (RoB 2). Inclusion criteria were: simulation studies with salivary cortisol collection and performance evaluation, published in any period in Portuguese, English and Spanish.

RESULTS

11 studies were included which measured stress using salivary cortisol and were analyzed using descriptive synthesis and qualitative analysis.

CONCLUSION

Some studies have shown a relationship between stress and performance, which may be beneficial or harmful to the participant. However, other studies did not show this correlation, which may not have been due to methodological issues.

Comparing the stress response using heart rate variability during real and simulated crises: a pilot study

Medical personnel often experience stress when responding to a medical emergency. A known stress-response is a measurable reduction in heart rate variability. It is currently unknown if crisis simulation can elicit the same stress response as real clinical emergencies. We aim to compare heart rate variability changes amongst medical trainees during simulated and real medical emergencies. We performed a single center prospective observational study, enrolling 19 resident physicians. Heart rate variability was measured in real time, using a 2-lead heart rate monitor (Bodyguard 2, Firstbeat Technologies Ltd) worn during 24 h critical care call shifts. Data was collected at baseline, during crisis simulation and when responding to medical emergencies. 57 observations were made to compare participant's heart rate variability. Each heart rate variability metric changed as expected in response to stress. Statistically significant differences were observed between baseline and simulated medical emergencies in Standard Deviation of the N-N interval (SDNN), Root mean square standard deviation of the N-N interval (RMSSD), Percentage of successive R-R intervals that differ by more than 50 ms (PNN50), Low Frequency (LF) and Low Frequency: High Frequency ratios (LF:HF). No statistically significant differences between simulated and real medical emergencies were identified in any heart rate variability metrics. We have shown using objective results, that simulation can elicit the same psychophysiological response as actual medical emergencies. Therefore, simulation may represent a reasonable way to practice not only essential skills in a safe environment but has the additional benefit of creating a realistic, physiological response in medical trainees.

Teaching cardiopulmonary resuscitation using virtual reality: A randomized study

BACKGROUND

The main functions of healthcare professionals include training and health education. In this sense, we must be able to incorporate new technologies and serious game to the teaching cardiopulmonary resuscitation.

METHODS

a multicenter, comparative and cross-sectional study was carried out to assess the learning of resuscitation of a group that was trained with the use of serious gaming with virtual reality, as compared to a control group trained with conventional classroom teaching.

RESULTS

the mean quality obtained in chest compressions for the virtual reality group was 86.1 % (SD 9.3), and 74.8 % (SD 9.5) for the control group [mean difference 11.3 % (95 % CI 6.6-16.0), p < 0.001]. Salivary Alpha-Amylase was 218.882 (SD 177.621) IU/L for the virtual reality group and 155.190 (SD 116.746) IU/L for the control group [mean difference 63.691 (95 % CI 122.998-4.385), p = 0.037].

CONCLUSION

using virtual reality and serious games can improve the quality parameters of chest compressions as compared to traditional training.

Relationship Between Cognitive Load Theory, Intrinsic Motivation and Emotions in Healthcare Professions Education: A Perspective on the Missing Link

Cognitive Load Theory (CLT) is one of the key cognitive theories that have been used to assess learners' information and working memory load. CLT has been applied to Simulation Based Education (SBE) and optimizing instructional design. However, a challenge that occurs is that these high-fidelity simulations and mannequins of critically ill patients can elicit negative emotions in learners which can unfavorably impact the learning process. There is also a potential for cognitive overload if the simulation is more authentic and requires more dynamic interactions and lead to high levels of anxiety due to a novel learning environment, which can also have detrimental effects on learning process. Hence, it is critical for health professional educators (HPE) to know how to minimize cognitive load to improve learning as a professional in a workplace setting. The literature on the role of emotions, intrinsic motivation, cognitive load is scarce in HPE literature. Specifically when not being studied together at once since they move dynamically together and affect the learning for the learner. Therefore, the purpose of this perspective paper is to cover the gap in the literature and propose a framework and recommendation for future HPE research.

Physiological Indicators of Fluency and Engagement during Sequential and Simultaneous Modes of Human-Robot Collaboration

OCCUPATIONAL APPLICATIONSAn understanding of fluency in human-robot teaming from a physiological standpoint is still incomplete. In our experimental study involving 24 participants, we designed a scenario for shared-space human-robot collaboration (HRC) for a material sorting task. When compared to a sequential mode of interaction, the simultaneous mode resulted in significantly higher perceptions of fluency and engagement, primarily by reducing human idle time. These observations were complemented by significant changes in physiological responses, such as ECG entropy and low frequency power. These responses could predict fluency and engagement with accuracies of 90 and 97%, respectively. Notably, the perception of fluency and preferred mode of interaction were influenced by individual preferences. Hence, it is crucial to consider both physiological responses and user preferences when designing HRC systems, to ensure a positive experience with the robot teammate and to foster engagement in long-term teamwork. Furthermore, these signals can be obtained using a single robust, low-cost, and comfortable sensor.

The Effectiveness of a Mindfulness Induction as a Buffer Against Stress Among University Students With and Without a History of Self-Injury

Stressful experiences are abundant in university and students with a history of nonsuicidal self-injury (NSSI) may be hyper-reactive to stress. While brief mindfulness inductions have been proposed as a buffer against acute stress, whether they function differently in students with a history of NSSI remains in question. This study sought to explore the impact of an online mindfulness induction on (a) two facets of state mindfulness (i.e., mind and body) and (b) state stress, following a stress induction task, in university students with versus without a history of NSSI. Participants were Canadian university students with (n = 82; Mage = 21.30 years, SD = 2.92; 87.8% female) and without (n = 82; Mage = 21.71 years, SD = 3.18; 87.8% female) a history of NSSI, matched on gender, age, and faculty, who completed baseline (T1) measures of state stress and state mindfulness. Participants were randomly assigned to complete a mindfulness induction or an active control task. All participants then underwent a stress induction, and again completed measures of state stress and state mindfulness (T2). Results from three-way mixed ANOVAs revealed that state stress increased from T1 to T2 for all participants, regardless of group or condition. Among those assigned to the control condition, state mindfulness of the body was lower at T2 for participants with a history of NSSI compared to those without such a history. However, participants with a history of NSSI who completed the mindfulness induction reported greater state mindfulness of the body at T2 than students with a history of NSSI who completed an active control task. Findings highlight the unique response of university students with a history of NSSI to a brief mindfulness induction. Implications are discussed in the context of future research and clinical applications.

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.

Heart rate responses in critical care trainees during airway intubation: a comparison between the simulated and clinical environments

OBJECTIVE

This study aimed to compare the heart rate response to stress during airway intubations in clinical practice and a simulated environment.

METHODS

Twenty-five critical care registrars participated in the study over a 3-month period. Heart rate data during intubations was recorded by a FitBit® Charge 2 worn by each participant during their clinical practice, and during a single simulated airway management scenario. The heart rate range was calculated by subtracting the baseline working heart rate (BWHR) from the maximum functional heart rate (MFHR). For each airway intubation performed participants recorded an airway diary entry. Data from intubations performed in the clinical environment was compared to data from a simulated environment. Heart rate changes were observed in two ways: percentage rise (median) across the 20-min intubation period and; percentage rise at point of intubation (median).

RESULTS

Eighteen critical care registrars completed the study, mean age 31.8 years (SD = 2.015, 95% CI = 30.85-32.71). Throughout the 20-min peri-intubation recording period there was no significant difference in the median change in heart rates between the clinical (14.72%) and simulation (15.96%) environment (p = 0.149). At the point of intubation there was no significant difference in the median change in heart rate between the clinical (16.03%) and the simulation (25.65%) environment groups (p = 0.054).

CONCLUSION

In this small population of critical care trainees, a simulation scenario induced a comparable heart rate response to the clinical environment during intubation. This provides evidence that simulation scenarios are able to induce a comparable physiological stress response to the clinical environment and thus facilitates effective teaching of a high-risk procedure in a safe manner.

The effectiveness and acceptability of formal versus informal mindfulness among university students with and without recent nonsuicidal self-injury: Protocol for an online, parallel-group, randomized controlled trial

BACKGROUND

Mindfulness-based programming comprising both formal (FM) and informal (IM) mindfulness practice is increasingly offered to university students. However, difficulties with emotion regulation, self-criticism, and a potentially complex relationship with their body may undermine the benefits of FM for students with a history of nonsuicidal self-injury (NSSI), given its requirement of sustained attention on thoughts, emotions, and bodily sensations. IM may be better tolerated by these students. This protocol describes a randomized controlled trial comparing a brief FM practice, a brief IM practice, and an active control task in university students with and without recent NSSI.

METHODS

Recruitment began in November 2022. An online, parallel-group, single-blind, randomized controlled trial will compare a 10-min, single-session FM practice, a 10-min, single session IM practice, and a 10-min, single session active control task in university students with and without recent NSSI. Outcomes will be assessed immediately pre-intervention and within five minutes post-intervention. The primary outcome will be state mindfulness. Secondary outcomes will be state stress, state well-being, and acceptability. Students with a history of NSSI are expected to report (i) greater improvements in state mindfulness, stress, and well-being, and (ii) greater acceptability in the IM condition, relative to the FM and control conditions. This distinction is not expected to occur in the no-NSSI comparison group.

CONCLUSION

This trial is the first to parse out the impacts of FM versus IM practice among university students with and without a history of self-injury. Findings will be relevant to academic and clinical audiences within university settings.

Applications of wireless sensor networks to improve occupational safety and health in underground mines

INTRODUCTION

The very complex and hazardous environment of underground mines may significantly contribute to occupational fatalities and injuries. Deploying wireless sensor network (WSN) technology has the potential to improve safety and health monitoring of miners and operators. However, the application of WSN in the industry is not fully understood and current research themes in this area are fragmented. Thus, there is a need for a comprehensive review that directly explores the contribution of WSNs to occupational safety and health (OSH) in underground mines.

METHOD

This study aims to conduct a systematic literature review on the existing applications of WSNs for improving OSH in the underground mining industry to pinpoint innovative research themes and their main achievements, reveal gaps and shortcomings in the literature, recommend avenues for future scholarly works, and propose potential safety interventions. The major contribution of this review is to provide researchers and practitioners with a holistic understanding of the integration of WSN applications into underground mine safety and health management.

RESULTS

The review results have been categorized and discussed under three predominant categories including location monitoring and tracking, physiological and body kinematics monitoring, and environmental monitoring. Finally, seven major directions for future research and practical interventions have been identified based on the existing research gaps including: (1) further applications of WSNs for underground mining OSH management; (2) application of WSNs from research to real-world practice; (3) big data analytics and management; (4) deploying multiple WSNs-based monitoring systems; (5) integration of WSNs with other communication systems; (6) adapting WSNs to the Internet of Things (IoT) infrastructure; and (7) autonomous WSNs.

Comparing the Psychological Effects of Manikin-Based and Augmented Reality-Based Simulation Training: Within-Subjects Crossover Study

BACKGROUND

Patient simulators are an increasingly important part of medical training. They have been shown to be effective in teaching procedural skills, medical knowledge, and clinical decision-making. Recently, virtual and augmented reality simulators are being produced, but there is no research on whether these more realistic experiences cause problematic and greater stress responses as compared to standard manikin simulators.

OBJECTIVE

The purpose of this research is to examine the psychological and physiological effects of augmented reality (AR) in medical simulation training as compared to traditional manikin simulations.

METHODS

A within-subjects experimental design was used to assess the responses of medical students (N=89) as they completed simulated (using either manikin or AR) pediatric resuscitations. Baseline measures of psychological well-being, salivary cortisol, and galvanic skin response (GSR) were taken before the simulations began. Continuous GSR assessments throughout and after the simulations were captured along with follow-up measures of emotion and cortisol. Participants also wrote freely about their experience with each simulation, and narratives were coded for emotional word use.

RESULTS

Of the total 86 medical students who participated, 37 (43%) were male and 49 (57%) were female, with a mean age of 25.2 (SD 2.09, range 22-30) years and 24.7 (SD 2.08, range 23-36) years, respectively. GSR was higher in the manikin group adjusted for day, sex, and medications taken by the participants (AR-manikin: -0.11, 95% CI -0.18 to -0.03; P=.009). The difference in negative affect between simulation types was not statistically significant (AR-manikin: 0.41, 95% CI -0.72 to 1.53; P=.48). There was no statistically significant difference between simulation types in self-reported stress (AR-manikin: 0.53, 95% CI -2.35 to 3.42; P=.71) or simulation stress (AR-manikin: -2.17, 95% CI -6.94 to 2.59; P=.37). The difference in percentage of positive emotion words used to describe the experience was not statistically significant between simulation types, which were adjusted for day of experiment, sex of the participants, and total number of words used (AR-manikin: -4.0, 95% CI -0.91 to 0.10; P=.12). There was no statistically significant difference between simulation types in terms of the percentage of negative emotion words used to describe the experience (AR-manikin: -0.33, 95% CI -1.12 to 0.46; P=.41), simulation sickness (AR-manikin: 0.17, 95% CI -0.29 to 0.62; P=.47), or salivary cortisol (AR-manikin: 0.04, 95% CI -0.05 to 0.13; P=.41). Finally, preexisting levels of posttraumatic stress disorder, perceived stress, and reported depression were not tied to physiological responses to AR.

CONCLUSIONS

AR simulators elicited similar stress responses to currently used manikin-based simulators, and we did not find any evidence of AR simulators causing excessive stress to participants. Therefore, AR simulators are a promising tool to be used in medical training, which can provide more emotionally realistic scenarios without the risk of additional harm.

Anxiety is associated with extraneous cognitive load during teaching using high-fidelity clinical simulation

High-fidelity clinical simulation is currently a well-established teaching tool. However, high-fidelity representations of patients in critical conditions have the potential to elicit emotions among learners and impact their cognitive load (CL). Teaching with clinical simulation may induce both emotional and cognitive overloads. The relationship between anxiety and CL during clinical simulation was studied. Forty-one undergraduate medical students participated in this study; 19 males and 22 females. The state-anxiety component of State-Trait Anxiety Inventory was administered during clinical simulation teaching sessions at time points: pre-scenario, post-scenario and post-debriefing. The Cognitive Load Scale (Leppink et al.) questionnaire was also completed post-scenario. This assessed the three components of CL: intrinsic cognitive load (ICL), extraneous cognitive load (ECL) and self-perceived learning (SPL). Median CL scores for ICL, ECL and SPL were compared between groups of low-anxiety and high-anxiety participants using a Mann-Whitney U test. State-anxiety scores were high for both the pre-scenario and post-scenario time points with a significant reduction following post-debriefing. The median (interquartile range) state-anxiety scores were 41.0 (33.0-50.0), 46.0 (33.0-52.0) and 31.0 (23.0-39.0) for the pre-scenario, post-scenario and post-debriefing time points respectively. Students with high state-anxiety had higher ECL scores (median = 2.0) than students with low state-anxiety (median = 0.9) at the post scenario time point (U = 220, p = 0.043). No statistical relation was seen with state-anxiety for either ICL or SPL. State-anxiety immediately after the simulation scenario is associated with ECL but not ICL or SPL.

Adapting RISE: meeting the needs of healthcare workers during the COVID-19 pandemic

The COVID-19 pandemic has placed extraordinary stresses on healthcare workers. Combined with disruptions to daily life outside of work, health care professionals experience a high prevalence of anxiety, depression, acute stress reaction, burnout, and PTSD. Top leaders at Johns Hopkins Medicine appreciated the mission-critical importance of maintaining the well-being and resilience of its essential workers. In March 2020 they asked the Johns Hopkins RISE (Resilience in Stressful Events) peer support program to help organize support for all staff. RISE made several adjustments, including adding virtual encounters to the usual in-person support, training additional peer responders, and rounding proactively on active units. Communication was broadened to reach less visible and lower wage workers. RISE collaborated actively with hospital epidemiology and infection control and began reporting regularly at incident command centre briefings. RISE also began to coordinate efforts with the other helping programs within the institution including the Office of Well-being, Employee Assistance, Spiritual Care, and Psychiatry. The number of calls and staff supported rose sharply. RISE supported over 4226 workers in the first 9 months of the pandemic. The adoption of RISE programs was accelerated at affiliated hospitals, as well as at other hospitals across the country in partnership with the Maryland Patient Safety Center. Experience with large scale disasters predicted correctly that worker distress would increase and persist beyond the initial wave of the pandemic. With subsequent surges of COVID-19, exhaustion and moral distress became nearly universal among workers. It is urgent for institutions to provide mechanisms to help their workers cope with the ongoing crisis and other crises that will inevitably occur in the future.

Impact of a Mobile App on Paramedics' Perceived and Physiologic Stress Response During Simulated Prehospital Pediatric Cardiopulmonary Resuscitation: Study Nested Within a Multicenter Randomized Controlled Trial

BACKGROUND

Out-of-hospital cardiac arrests (OHCAs) are stressful, high-stake events that are associated with low survival rates. Acute stress experienced in this situation is associated with lower cardiopulmonary resuscitation performance in calculating drug dosages by emergency medical services. Children are particularly vulnerable to such errors. To date, no app has been validated to specifically support emergency drug preparation by paramedics through reducing the stress level of this procedure and medication errors.

OBJECTIVE

This study aims to determine the effectiveness of an evidence-based mobile app compared with that of the conventional preparation methods in reducing acute stress in paramedics at the psychological and physiological levels while safely preparing emergency drugs during simulated pediatric OHCA scenarios.

METHODS

In a parent, multicenter, randomized controlled trial of 14 emergency medical services, perceived and physiologic stress of advanced paramedics with drug preparation autonomy was assessed during a 20-minute, standardized, fully video-recorded, and highly realistic pediatric OHCA scenario in an 18-month-old child. The primary outcome was participants' self-reported psychological stress perceived during sequential preparations of 4 intravenous emergency drugs (epinephrine, midazolam, 10% dextrose, and sodium bicarbonate) with the support of the PedAMINES (Pediatric Accurate Medication in Emergency Situations) app designed to help pediatric drug preparation (intervention) or conventional methods (control). The State-Trait Anxiety Inventory and Visual Analog Scale questionnaires were used to measure perceived stress. The secondary outcome was physiologic stress, measured by a single continuous measurement of the participants' heart rate with optical photoplethysmography.

RESULTS

From September 3, 2019, to January 21, 2020, 150 advanced paramedics underwent randomization. A total of 74 participants were assigned to the mobile app (intervention group), and 76 did not use the app (control group). A total of 600 drug doses were prepared. Higher State-Trait Anxiety Inventory-perceived stress increase from baseline was observed during the scenario using the conventional methods (mean 35.4, SD 8.2 to mean 49.8, SD 13.2; a 41.3%, 35.0 increase) than when using the app (mean 36.1, SD 8.1 to mean 39.0, SD 8.4; a 12.3%, 29.0 increase). This revealed a 30.1% (95% CI 20.5%-39.8%; P<.001) lower relative change in stress response in participants who used the app. On the Visual Analog Scale questionnaire, participants in the control group reported a higher increase in stress at the peak of the scenario (mean 7.1, SD 1.8 vs mean 6.4, SD 1.9; difference: -0.8, 95% CI -1.3 to -0.2; P=.005). Increase in heart rate during the scenario and over the 4 drugs was not different between the 2 groups.

CONCLUSIONS

Compared with the conventional method, dedicated mobile apps can reduce acute perceived stress during the preparation of emergency drugs in the prehospital setting during critical situations. These findings can help advance the development and evaluation of mobile apps for OHCA management and should be encouraged.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03921346; https://clinicaltrials.gov/ct2/show/NCT03921346.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s13063-019-3726-4.

Measurement of Trauma Caregiver Stress: Validation of Heart rate variability in a Real-World Surgical Setting

BACKGROUND

Acute stress is a potentially modifiable risk-factor that contributes to errors in trauma care. Research on stress mitigation is limited by the lack of a validated objective measure of surgeon stress. We sought to validate HRV in a real-world surgical setting by comparison to the Subjective Units of Distress Score (SUDS), and correlation with self-reported peak stress moments.

METHODS

Attending and resident surgeons on the trauma team at a Level I Trauma Center wore armbands to measure HRV. Stress-associated blunting of HRV was analyzed using the standard deviation of N-N intervals (SDNN) and the root mean square of successive differences . Perceived stress was measured with the SUDS at random intervals and at perceived stress peaks. SUDS and HRV metrics were compared with a mixed effect regression model. Correlation between binned SUDS quartiles and HRV was evaluated. HRV at reported peak-stress moments were compared to shift baseline values.

RESULTS

Twelve participants were monitored for 340 h, producing 135 SUDS responses and 65 peak-stress time points. Regression analysis demonstrated no correlation between HRV and SUDS. With a binned approach, decreased SDNN was associated with an elevated SUDS (P = 0.03). The self-identified peak-stress moments correlated with decreases in both SDNN and root mean square of successive differences (P = 0.02; P < 0.01).

CONCLUSIONS

HRV by SDNN analysis correlated with heightened perceived stress, supporting its validity as a measure. However, the wide, frequent variation of HRV tracings within subjects, the sensitivity of HRV to of analytic technique, and the impact of confounders may limit its utility as an education or research tool.

LEVEL OF EVIDENCE

V Diagnostic test.

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.

Do Rescuers' Physiological Responses and Anxiety Influence Quality Resuscitation under Extreme Temperatures?

Teaching and training cardiopulmonary resuscitation (CPR) through simulation is a priority in Health Sciences degrees. Although CPR is taught as a simulation, it can still be stressful for the trainees since it resembles a real-life circumstance. The aim of this study was to assess the physiological effects and anxiety levels of health sciences undergraduates when faced with CPR process in different temperatures (room temperature, extremely cold, or extremely warm). This was a descriptive cross-sectional before–after study conducted during the 2018/2019 academic year with 59 students registered in the Faculty of Health Sciences of the Castilla-La Mancha University (UCLM). State Trait Anxiety Inventory (STAI) questionnaires were distributed among the students before and after the CPR simulation. We found greater level of situational anxiety in undergraduates faced with extreme adverse temperature scenarios (extreme heat and cold), especially in conditions of extreme heat compared to controlled environment (at room temperature). We discovered differences regarding sex, in which men scored 6.4 ± 5.55 points (STAI after CPR score) and women scored 10.4 ± 7.89 points (STAI after CPR score). Furthermore, there was less lactate in blood, before and during the event in individuals with anxiety. In addition, beginning in Minute 7, we observed a remarkable decrease (but not significant) in the performance of rescuers with anxiety. Programs targeted at promoting coping mechanisms to reduce anxiety before a critical clinic situation should be implemented in academic training.

Triage in Complex, Coordinated Terrorist Attacks

INTRODUCTION

Terror attacks have increased in frequency, and tactics utilized have evolved. This creates significant challenges for first responders providing life-saving medical care in their immediate aftermath. The use of coordinated and multi-site attack modalities exacerbates these challenges. The use of triage is not well-validated in mass-casualty settings, and in the setting of intentional mass violence, new and innovative approaches are needed.

METHODS

Literature sourced from gray and peer-reviewed sources was used to perform a comparative analysis on the application of triage during the 2011 Oslo/Utoya Island (Norway), 2015 Paris (France), and 2015 San Bernardino (California USA) terrorist attacks. A thematic narrative identifies strengths and weaknesses of current triage systems in the setting of complex, coordinated terrorist attacks (CCTAs).

DISCUSSION

Triage systems were either not utilized, not available, or adapted and improvised to the tactical setting. The complexity of working with large numbers of patients, sensory deprived environments, high physiological stress, and dynamic threat profiles created significant barriers to the implementation of triage systems designed around flow charts, physiological variables, and the use of tags. Issues were identified around patient movement and "tactical triage."

CONCLUSION

Current triage tools are inadequate for use in insecure environments, such as the response to CCTAs. Further research and validation are required for novel approaches that simplify tactical triage and support its effective application. Simple solutions exist in tactical triage, patient movement, and tag use, and should be considered as part of an overall triage system.

Focusing attention on biological markers of acute stressor intensity: Empirical evidence and limitations

ARMARIO, A, J. Labad and R. Nadal. Focusing attention on biological markers of acute stressor intensity: empirical evidence and limitations. NEUROSCIENCE AND BIOBEHAVIORAL REVIEWS. The availability of biological markers that objectively quantify stress is a highly relevant issue. However, experimental evidence suggests that most physiological changes elicited by emotional stressors do not reflect their intensity and are not useful for this purpose. Thus, we review experimental evidence in animals and humans about the putative validity of neuroendocrine and sympathetic/parasympathetic variables to measure stress. Plasma levels of some hormones (e.g. ACTH, glucocorticoids, prolactin and catecholamines) have been found to reflect, at least under certain conditions, the intensity of emotional stressors in animals and probably in humans. However, the temporal resolution of hormone changes is insufficient to reflect the very dynamic psychological processes taking place while experiencing stressors. Cardiovascular parameters (e.g. heart rate and blood pressure) have much better temporal resolution but their validity as markers of stressor intensity either in animals or humans is problematic. Skin conductance and pupil dilation appear to be promising. Additional and more systematic studies are needed to demonstrate the actual validity of stress-induced physiological changes to quantify stress.

Self-Reported Emotions in Simulation-Based Learning: Active Participants vs. Observers

INTRODUCTION

Experiential learning through active participation is thought to be a key benefit of simulation-based education. Recent research has challenged this assumption, suggesting that active participants learn just as well as observers. Studies report that active participants experience stress and anxiety during simulation, which may hamper learning by active participants. We undertook the current study to examine whether active participation results in different emotional arousal than observing during simulation. We hypothesized that participants in active roles experience higher levels of negative emotions than those observing and looked for evidence that this may impact learning.

METHODS

Pediatric residents participate in simulations, rotating through active and observer roles, as part of their standard curriculum. We assessed both positive and negative emotional arousal with the Positive and Negative Affect Scale immediately after each simulation and assessed learning through multiple-choice questions. We used repeated measures analysis of variance to examine potential interactions between Positive and Negative Affect Scale scores and role in simulation. To explore differences in learning, we examined whether knowledge retention differed between the groups.

RESULTS

Residents had higher levels of both positive and negative emotional arousal in active roles compared with observing roles. We could not detect a difference in learning between the roles.

CONCLUSIONS

The increase in both positive and negative emotions among active participants compared with observers may have important implications for simulation design and participant learning. Future studies should be powered to detect differences in learning and examine the impact of contributing factors such as learner level and context.

Does simulation-based training in medical education need additional stressors? An experimental study

The increased curricular integration of simulation-based training (SBT) in medical education is accompanied by researchers' calls to examine the effectiveness of SBT. We address conflicting results regarding effects of an added stressor on learning outcomes. In an experimental setting, one group of medical students (N = 20) performed cardiopulmonary resuscitation on a patient simulator. For a second group (N = 21) the scenario differed in that they encountered a defect defibrillator. We found participants of both groups to show increased biological stress-levels, independent of group allocation. Paradoxically, participants who encountered the equipment failure subjectively reported less stress. We discuss the implications of the comparable high stress levels in both groups with regards to future studies. We further discuss the result regarding subjective stress levels within the framework of attribution theory. Practitioner summary: The results of our experimental study underline the need for evidence-based choices of additional stressors for the design of simulation scenarios. We describe the choice of stimuli and setting in detail to maximise practical value for the construction of simulation-based medical trainings.

Physiological synchronization and entropy as measures of team cognitive load

The operating room (OR) is a high-risk and complex environment, where multiple specialized professionals work as a team to effectively care for patients in need of surgical interventions. Surgical tasks impose high cognitive demands on OR staff and cognitive overload may have deleterious effects on team performance and patient safety. The aim of the present study was to investigate the feasibility and describe a novel methodological approach to characterize dynamic changes in team cognitive load by measuring synchronization and entropy of heart rate variability parameters during real-life cardiac surgery. Cognitive load was measured by capturing interbeat intervals (IBI) from three team members (surgeon, anesthesiologist and perfusionist) using an unobtrusive wearable heart rate sensor and transmitted in real-time to a smartphone application. Clinical data and operating room audio/video recordings were also collected to provide behavioral and contextual information. We developed symbolic representations of the transient cognitive state of individual team members (Individual Cognitive State - ICS), and overall team (Team Cognitive State - TCS) by comparing IBI data from each team member with themselves and with others. The distribution of TCS symbols during surgery enabled us to display and analyze temporal states and dynamic changes of team cognitive load. Shannon's entropy was calculated to estimate the changing levels of team organization and to detect fluctuations resulting from a variety of cognitive demands and/or specific situations (e.g. medical error, emergency, flow disruptions). An illustrative example from a real cardiac surgery team shows how cognitive load patterns shifted rapidly after an actual near-miss medication event, leading the team to a more organized and synchronized state. The methodological approach described in this study provides a measurement technique for the assessment of team physiological synchronization, which can be applied to many other team-based environments. Future research should gather additional validity evidence to support the proposed methods for team cognitive load measurement.

Endocrine and psychological stress response in simulated doctor-patient interactions in medical education

BACKGROUND

Training of doctor-patient interactions by means of patient actors is considered a useful didactic tool in medical education. However, though students report it as being highly stressful little systematic research has verified this notion.

AIMS

To assess the endocrine and psychological stress responses of students in the doctor vs. the observer role in simulated doctor-patient interactions.

METHODS

Salivary cortisol and anxiety was assessed in N = 86 participants of a mandatory course on doctor-patient interactions on three consecutive days. During two of these days they were in the observer role and gave feedback to another student and on one of these days they were in the doctor role and were being given feedback. Saliva was sampled at 4 points in time per day: prior to interaction (T1); after watching the video of the interaction (T2); after feedback (T3); after observation of another interaction (T4). Assessments on observer days took place at the respective time points and at the same time of the day. 3-way mixed ANOVAs were computed with the factors "day of data sampling" (F1); "day with doctor role" (F2); "measurement time"(F3).

RESULTS

Significant two-way interactions F1 × F2 and three-way interactions F1 × F2 × F3 were observed both for cortisol and for anxiety (all p < .001). Neither cortisol nor anxiety were related to task severity. Anxiety at T1 correlated with cortisol increase from T1 to T2 (r = .266; p = .013).

DISCUSSION

Results confirm that playing the doctor role in a simulated doctor-patient interaction represents a significant stressor in medical students. Effect sizes considerably exceed those observed in laboratory stress. This brings about new questions regarding moderating factors, effects of repetitions and relationship to medical performance. The ecological validity of this stressor can also make it a useful tool in basic endocrine research.

Comparison of the psychological and physiological effects on students of a video-assisted or text introduction to a simulated task

Introduction

The use of different methods for introducing the scenario in simulation-based medical education has not been investigated before and may be a useful element to optimise the effectiveness of learning. The aim of this study was to compare an immersive video-assisted introduction to a minimal text-based one, with regard to emotional assessment of the situation.

Methods

In this pilot study, 39 students participated in a medical simulated scenario. The students were randomly assigned to an experimental group (video-assisted introduction) or a control group (minimal textual introduction) and both were followed by performing surgery on LapSim (Surgical Science, Gothenburg, Sweden). The emotional assessment of the situation, cognitive appraisal, was defined as the ratio of the demands placed by an individual’s environment (primary appraisal) to that person’s resources to meet the demands (secondary appraisal). Secondary outcomes were anxiety (State-Trait Anxiety Inventory), physiological parameters (heart rate, heart rate variability, skin conductance, salivary cortisol), engagement (Game Engagement Questionnaire), motivation (Intrinsic Motivation Inventory) and performance (mean score in percentage calculated by LapSim of predefined levels).

Results

Participants in the immersive video group (n=17) were overloaded in terms of their perceived demands (a ratio of 1.17, IQR 0.30) compared with those in the control group (a ratio of 1.00, IQR 0.42, n=22) (P=0.01). No significant differences were found between the groups in secondary outcomes. Both groups showed an increase of anxiety after the introduction method. In the experimental group, this score increased from 9.0 to 11.0, and in the textual group from 7.5 to 10.5, both P<0.01.

Discussion

This study shows that the method of introducing a simulated scenario may influence the emotional assessment of the situation. It may be possible to make your simulation introduction too immersive or stimulating, which may interfere with learning. Further research will be necessary to investigate the impact and usefulness of these findings on learning in simulation-based medical education.

Comparison of knowledge retention between high-fidelity patient simulation and read-only participants in undergraduate biomedical science education

High-fidelity patient simulation (HFPS) is expensive in money and faculty resources. There has been a recent push to increase the use of HFPS for undergraduates to teach basic science. However, it is still unclear if HFPS is superior to other cost-effective modalities for learning, and there have been limited studies comparing HFPS directly with other methods. The purpose of this study was to compare learning between three groups: 1) students who participated in a HFPS after reading material (RS); 2) students who reread material (RR) individually; and 3) students who had no intervention or reading (CON). Quizzes (10 true/false questions) were given presimulation, immediately after the simulation (post-sim 1), and 1 wk later to all groups (post-sim 2). Ninety-seven undergraduate students consented to include their data in the study. All groups scored the same on the presimulation quiz (median of 6). The RR and RS scored significantly higher than the CON group on post-sim 1 (medians 8 vs. 6). All groups performed similarly on post-sim 2. A questionnaire also showed that students had increased perceived confidence about pathophysiology. These data suggest that a single-time use of HFPS for knowledge learning for undergraduate students is not more effective than other methods. Future studies need to determine whether increasing the number of HFPS and developing social learning networks could make HFPS more effective for undergraduates. Additionally, future studies should focus on soft skill development, such as confidence, critical thinking, and teamwork/communication skills, as opposed to knowledge acquisition.

Trauma Simulation in Prehospital Emergency Care

Well-educated ambulance staff is a prerequisite for high-quality prehospital trauma care. The aim of this study was to examine how nurses in the ambulance service experienced participation in trauma simulation. Sixty-one nurses, working in an emergency ambulance service, performed simulated trauma care on four different occasions and afterward rated three statements on a 5-point Likert scale. A descriptive and inferential analysis was conducted. There are statistically significant increases between the pre- and posttests regarding all three statements: "I think simulation of severe trauma with manikins is realistic" (0.23 or 6% increase), "Simulation is a suitable method for learning severe trauma care" (1.3 or 38% increase), and "I am comfortable in the situation learning severe trauma care through simulation" (0.74 or 19% increase). With the experience of realism in simulation, participants become more motivated to learn and prepare for future events. If the participants instead feel uncomfortable during simulation training, they focus on their own feelings instead of learning. In a realistic simulated environment, participants are prepared to understand and manage the emergency care situation in clinical work. Participants learn during simulation when they are outside their comfort zone but without being uncomfortable or experiencing anxiety.

A novel simulation competition format as an effective instructional tool in post-graduate medical education

Objective

Medical simulation competitions are a growing reality. This study aims at exploring if a novel format of simulation competition (SIMCUP) can be an effective educational format in post-graduate education.

Design

We designed a 2-day event that included scientific educational lectures, an orientation to the competition, familiarization with the simulation lab, and competition time. Day 1 was devoted to preliminary rounds and was structured using an Objective Structured Clinical Examination (OSCE)-like system. On day 2, the first four teams advanced to semi-finals and then to finals, which were held using a classical SimWars style.

Setting and subjects

A total of 14 four-participant teams participated in the event over two editions (Ed.1 in 2015 and Ed.2 in 2016).

Interventions

External referees evaluated both technical and non-technical skills for each simulated scenario. Each participant was also administered pre- and post-test questionnaires covering self-perception about the confidence in managing simulated clinical cases, educational effectiveness, satisfaction with the simulation experience, and previous simulation training.

Main results

Overall participants found SIMCUP a useful learning experience, rating it 10 [9, 10] and 10 [7.75–10] out of 10 for Ed.1 and Ed.2, respectively. Participants reported, using a 10-point semantic differential scale ranging from “1 - strongly disagree.” to “10 - strongly agree,” finding both days to be educationally effective: day 1 was rated 9 [7–10] and 9 [8–10] as day 2 was rated 8 [7–10] and 8 [7–10] for Ed. 1 and Ed. 2, respectively.

Participants’ self-perception regarding the confidence of managing the specific scenarios significantly improved immediately after the event as measured by pre- and post-questionnaires for all stations and during both editions.

Conclusion

This study suggests that simulation competition can serve as an effective instructional format in residency training.

Electronic supplementary material

The online version of this article (10.1186/s41077-018-0075-4) contains supplementary material, which is available to authorized users.

An In Situ Simulation-Based Training Approach to Active Shooter Response in the Emergency Department

With an increased number of active shooter events in the United States, emergency departments are challenged to ensure preparedness for these low frequency but high stakes events. Engagement of all emergency department personnel can be very challenging due to a variety of barriers. This article describes the use of an in situ simulation training model as a component of active shooter education in one emergency department. The educational tool was intentionally developed to be multidisciplinary in planning and involvement, to avoid interference with patient care and to be completed in the true footprint of the work space of the participants. Feedback from the participants was overwhelmingly positive both in terms of added value and avoidance of creating secondary emotional or psychological stress. The specific barriers and methods to overcome implementation are outlined. Although the approach was used in only one department, the approach and lessons learned can be applied to other emergency departments in their planning and preparation. (Disaster Med Public Health Preparedness. 2019;13:345–352)

Effect of Simulation on Learner Stress as Measured by Cortisol: An Integrative Review

Simulated learning has become a mainstay in nursing education. Current literature focuses primarily on the development and implementation of simulation, although little is known about the stress that students experience. This integrative review examines studies evaluating learner stress in simulated settings as measured by cortisol. Findings suggest that cortisol is a valid measure of stress in simulation. Evidence is inconclusive on whether elevated stress during simulation promotes performance.

Acute stress in residents playing different roles during emergency simulations: a preliminary study

OBJECTIVES

To investigate acute stress response in residents playing nurse and physician roles during emergency simulations.

METHODS

Sixteen second-year internal medicine residents participated in teams of four (two playing physician roles and two playing nurse roles). Stress markers were assessed in 24 simulations at baseline (T1) and immediately after the scenario (T2), using heart rate, systolic and diastolic blood pressure, salivary α-amylase, salivary cortisol and salivary interleukin-1β. The State-Trait Anxiety Inventory was applied at T2. Continuous data were summarized for the median (1st-3rd interquartile ranges), and the Mann-Whitney U Test was used to compare the groups.

RESULTS

The percent variations of the stress markers in the physician and nurse roles, respectively, were the following: heart rate: 70.5% (46.0-136.5) versus 53.0% (29.5-117.0), U=89.00, p=0.35; systolic blood pressure: 3.0% (0.0-10.0) versus 2.0% (-2.0-9.0), U=59.50, p=0.46; diastolic blood pressure: 5.5% (0.0-13.5) versus 0.0% (0.0-11.5), U=91.50, p=0.27; α-amylase: -5.35% (-62.70-73.90) versus 42.3% (12.4-133.8), U=23.00, p=0.08; cortisol: 35.3% (22.2-83.5) versus 42.3% (12.4-133.8), U=64.00, p=0.08); and interleukin-1β: 54.4% (21.9-109.3) versus 112.55% (29.7-263.3), U= 24.00, p=0.277. For the physician and nurse roles, respectively, the average heart rate was 101.5 (92.0-104.0) versus 91.0 (83.0-99.5) beats per minute, U=96.50, p=0.160; and the state anxiety inventory score was 44.0 (40.0-50.0) versus 42.0 (37.50-48.0) points, U= 89.50, p=0.319.

CONCLUSIONS

Different roles during emergency simulations evoked similar participants' engagement, as indicated by acute stress levels. Role-play strategies can provide high psychological fidelity for simulation-based training, and these results reinforce the potential of role-play methodologies in medical education.

Simulated Mortality-We Can Do More

High-fidelity simulation (HFS) is a relatively new teaching modality, which is gaining widespread acceptance in medical education. To date, dozens of studies have proven the usefulness of HFS in improving student, resident, and attending physician performance, with similar results in the allied health fields. Although many studies have analyzed the utility of simulation, few have investigated why it works. A recent study illustrated that permissive failure, leading to simulated mortality, is one HFS method that can improve long-term performance. Critics maintain, however, that the use of simulated death is troubling and excessive. Given the controversy regarding simulated death, we consider the data about the educational value and the emotional harms associated with them, expecting that evidence could be useful in resolving the question. The goal of this narrative review is to explore the argument against simulated mortality and provide educators with an imperative as to why it can be safely utilized.

Acute stress in residents during emergency care: a study of personal and situational factors

Providing care for simulated emergency patients may induce considerable acute stress in physicians. However, the acute stress provoked in a real-life emergency room (ER) is not well known. Our aim was to assess acute stress responses in residents during real emergency care and investigate the related personal and situational factors. A cross-sectional observational study was carried out at an emergency department of a tertiary teaching hospital. All second-year internal medicine residents were invited to voluntarily participate in this study. Acute stress markers were assessed at baseline (T1), before residents started their ER shift, and immediately after an emergency situation (T2), using heart rate, systolic, and diastolic blood pressure, salivary α-amylase activity, salivary interleukin-1 β, and the State-Trait Anxiety Inventory (STAI-s and STAI-t). Twenty-four residents were assessed during 40 emergency situations. All stress markers presented a statistically significant increase between T1 and T2. IL-1 β presented the highest percent increase (141.0%, p < .001), followed by AA (99.0%, p = .002), HR (81.0%, p < .001), DBP (8.0%, p < .001), and SBP (3.0%, p < .001). In the multivariable analysis, time of residency had a negative correlation with HR during the emergency (adjusted R-square = .168; F = 8.69; p = .006), SBP response (adjusted R-square = .210; F = 6.19; p = .005) and DBP response (adjusted R-square = .293; F = 9.09; p = .001). Trait anxiety (STAI-t) was positively correlated with STAI-s (adjusted R-square = .326; F = 19.9; p < .001), and number of procedures performed during emergency care had a positive association with HR response (adjusted R-square = .241; F = 5.02; p = .005). In the present study, emergency care provoked substantial acute stress in residents. Resident experience, trait anxiety, and number of emergency procedures were independently associated with acute stress response.

Comparison of Psychophysiological Stress in Physiotherapy Students Undertaking Simulation and Hospital-Based Clinical Education

INTRODUCTION

Simulation-based clinical education often aims to replicate varying aspects of real clinical practice. It is unknown whether learners' stress levels in simulation are comparable with those in clinical practice. The current study compared acute stress markers during simulation-based clinical education with that experienced in situ in a hospital-based environment.

METHODS

Undergraduate physiotherapy students' (n = 33) acute stress responses [visual analog scales of stress and anxiety, continuous heart rate (HR), and saliva cortisol] were assessed during matched patient encounters in simulation-based laboratories using standardized patients and during hospital clinical placements with real patients. Group differences in stress variables were compared using repeated measures analysis of variance for 3 time points (before, during the patient encounter, and after) at 2 settings (simulation and hospital).

RESULTS

Visual analog scale stress and anxiety as well as HR increased significantly from baseline levels before the encounter in both settings (all P < 0.05). Stress and anxiety were significantly higher in simulation [mean (SD), 45 (22) and 44 (25) mm; P = 0.003] compared with hospital [mean (SD), 31 (21) and 26 (20) mm; P = 0.002]. The mean (SD) HR during the simulation patient encounter was 90 (16) beats per minute and was not different compared with hospital [mean (SD), 87 (15) beats per minute; P = 0.89]. Changes in salivary cortisol before and after patient encounters were not statistically different between settings [mean (SD) simulation, 1.5 (2.4) nmol/L; hospital, 2.5 (2.9) nmol/L; P = 0.70].

CONCLUSIONS

Participants' experienced stress on clinical placements, irrespective of the clinical education setting (simulation vs. hospital). This study revealed that psychological stress and anxiety were greater during simulation compared with hospital settings; however, physiological stress responses (HR and cortisol) were comparable. These results indicate that psychological stress may be heightened in simulation, and health professional educators need to consider the impact of this on learners in simulation-based clinical education. New learners in their clinical education program may benefit from a less stressful simulation environment, before a gradual increase in stress demands as they approach clinical practice.

The effects of active (hot-seat) versus observer roles during simulation-based training on stress levels and non-technical performance: a randomized trial

BACKGROUND

Active 'hands-on' participation in the 'hot-seat' during immersive simulation-based training (SBT) induces stress for participants, which is believed to be necessary to improve performance. We hypothesized that observers of SBT can subsequently achieve an equivalent level of non-technical performance as 'hot-seat' participants despite experiencing lower stress.

METHODS

We randomized 37 anaesthesia trainees into two groups to undergo three consecutive SBT scenarios. Eighteen 'hot-seat' trainees actively participated in all three scenarios, and 19 'observer' trainees were directed to observe the first two scenarios and participated in the 'hot-seat' only in scenario 3. Salivary cortisol (SC) was measured at four time points during each scenario. Primary endpoint for stress response was the change in SC (ΔSC) from baseline. Performance was measured using the Anaesthetist's Non-Technical Skills (ANTS) Score.

RESULTS

Mean SC increased in all participants whenever they were in the 'hot-seat' role, but not when in the observer role. Hot-seat ΔSC (mcg/dL) for scenarios 1, 2, and 3 were 0.122 (p = 0.001), 0.074 (p = 0.047), and 0.085 (p = 0.023), respectively. Observers ΔSC (mcg/dL) for scenarios 1, 2, and 3 were -0.062 (p = 0.091), 0.010 (p = 0.780), and 0.144 (p = 0.001), respectively. Mean ANTS scores were equivalent between the 'hot-seat' (40.0) and 'observer' (39.4) groups in scenario 3 (p = 0.733).

CONCLUSIONS

Observers of SBT achieved an equivalent level of non-technical performance, while experiencing lower stress than trainees repeatedly trained in the 'hot-seat'. Our findings suggest that directed observers may benefit from immersive SBT even without repeated 'hands-on' experience and stress in the hot-seat. The directed observer role may offer a less stressful, practical alternative to the traditional 'hot-seat' role, potentially rendering SBT accessible to a wider audience.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT02211378, registered August 5, 2014, retrospectively registered.

[Emergency medical training through simulation : Always the same for everyone?]

Simulation assumes a growing importance in the field of emergency medical education. Many rescue service schools work with simulators or even have their own simulation center. Classic resuscitation training in the classroom is increasingly being replaced by realistic case scenarios. But simulators themselves do not train! Using a simulator in emergency medical training does not necessarily mean achieving sustained learning success among the participants. Depending on the skills, abilities or competences being taught, there seems to be different requirements for simulation. However, there is no scientific evidence about how strong learners should be stressed in order to achieve the best learning effect. However, it can be stated that for training purely technical skills, simulators that represent the anatomical or physiological reality as accurately as possible should be used. If soft skills, practical knowledge and decision-making are the learning objectives, a scenario with extremly realistic conditions needs to be embedded. Mid-fidelity simulators seem to be able to cover the widest range of imparting skills for emergency medical training. No matter what simulator is used, the following applies: The selected scenario must be realistic and the simulation as well as technical capabilities of the simulator must be coordinated. A well-presented scenario with a well-trained teacher using a simple resuscitation doll appears to be better than a highly complex, however unrealistic, amateur simulation scenario for successful learning.

Reduced Cortisol Output during Public Speaking Stress in Ostracized Women

Ostracism (being excluded or ignored) is experienced as unpleasant and distressing. In previous studies, an immediate pre-stress experience of ostracism induced by Cyberball, a virtual ball-tossing game, was found to inhibit cortisol reactivity to public speaking stress in female students. The present study examines whether the effect will persist when a 15-min time gap between the Cyberball experience and subsequent psychological stress is introduced. N = 84 women were randomly assigned to Cyberball ostracism vs. inclusion. 15 min after playing Cyberball, all women were subjected to public speaking stress. Salivary cortisol and mood were repeatedly assessed during the course of the experiment. These are the main findings of the study: Repeated measures ANCOVA revealed that public speaking stress resulted in a significant increase of cortisol in both groups (inclusion vs. ostracism). However, cortisol levels were significantly lower in the ostracism group. In earlier studies when Cyberball was played immediately before public speaking stress, the cortisol response to public speaking was completely suppressed in ostracized women. By introducing a waiting period between Cyberball and public speaking stress in the present study, the main effect of an ostracism induced reduction of cortisol remained, although both groups showed an increase of cortisol as a response to public speaking. These results again suggest that the experience of ostracism might inhibit hypothalamic-pituitary-adrenal (HPA) axis activity, thereby confirming previous results. The formerly observed total suppression of HPA axis responsiveness to public speaking, however, seems to be a rather short-term effect.

How stressful is the Newborn Life Support airway test? An observational study

Objectives

To determine whether there is a significant stress response to the Newborn Life Support airway test (NLSAT) among healthcare professionals in the UK.

Design

Quantitative study measuring both stress and anxiety of candidates on Newborn Life Support (NLS) courses measuring salivary cortisol levels along with validated anxiety questionnaires (State Trait Anxiety Inventory).

Setting

UK NLS course centres.

Participants

80 healthcare professionals (nurses, doctors and midwives) on NLS courses.

Interventions

Stress levels measured (cortisol swabs and State-Trait Anxiety Inventory (STAI)) at baseline, immediately before and 20 min after starting the NLSAT.

Results

Cortisol measurements failed to detect any significant rise in stress levels as a result of the NLSAT. Significant anxiety was induced by the NLSAT based on STAI scores. STAI scores rose significantly in all professionals from baseline to post-NLSAT, with the greatest change detected for midwives (+11.82 (SD 7.64, p<0.001)) compared with nurses (+8.86 (SD 12.1, p<0.001)) and doctors (+7.96 (SD 2.9.69, p<0.001)). Experience had no impact on stress levels.

Conclusions

Anxiety levels induced by the NLSAT are significant and should be considered when instructing and developing the NLS course.

An experimental investigation into the extent social evaluation anxiety impairs performance in simulation-based learning environments amongst final-year undergraduate nursing students

BACKGROUND

While numerous theoretical and conceptual models suggest social evaluation anxiety would likely influence performance in simulation-based learning environments, there has been surprisingly little research to investigate the extent to which this is true.

METHODS

Final-year Bachelor of Science (Nursing) students (N=70) were randomly assigned to complete one of three clinically identical simulation-based scenarios designed to elicit varying levels of social evaluation anxiety by manipulating the number of other people present with the student during the simulation (1, 2 or 3 others). Rises in acute stress were measured via continuous heart-rate and salivary cortisol. Performance scores were derived from the average of two independent raters' using a structured clinical checklist (/16).

RESULTS

Statistically different increases were found within the first minute of the simulation between those students with one versus three other people in the room (+4.13 vs. +14.01beats-per-minute respectively, p=0.01) and salivary cortisol measures suggested significantly different changes in anxiety between these groups (-0.05 vs. +0.11μg/dL respectively, p=0.02). Independent assessments suggested students with only one other person accompanying them in the simulation significantly outperformed those accompanied by three others (12.95 vs. 10.67 respectively, p=0.03).

DISCUSSION

Students accompanied by greater numbers during simulations experienced measurably greater anxiety and measurably poorer performances. These results demonstrate the ability to manipulate social evaluation anxiety within high-fidelity simulation training of undergraduates in order to help students better acclimatise to stressful events prior to practising in real clinical settings.

Anxiety and stress among anaesthesiology and critical care residents during high-fidelity simulation sessions

OBJECTIVES

High-fidelity simulation (HFS) calls heavily upon cognitive capacities and generates stress and anxiety. The objectives of this prospective, observational study were to assess trait anxiety and fear of negative evaluation (FNE) in anaesthesiology and critical care residents and appraise their state anxiety levels and cardiovascular responses during HFS training sessions.

SUBJECTS AND METHODS

First-year anaesthesiology and critical care residents completed the French-Canadian adaptation of the State-Trait Anxiety Inventory (IASTA Y-1: state anxiety, IASTA Y-2: trait anxiety) and the French adaptation of the Fear of Negative Evaluation Scale (FNE). Their heart rate (HR) and blood pressure (BP) were assessed before and after the training session.

RESULTS

Twenty-three residents (8 women, 15 men) were included in the study. IASTA Y-1 and Y-2 scores were low (respectively 40.2±9.9 and 39.7±8) and FNE scores were moderate (16.7±5.5). HR measurements before and after the training sessions were significantly higher than at rest (respectively 78±19, 80±17 and 63±9b/min; P<0.001). BP measurements before and after the HFS sessions were not significantly different. The IASTA Y-2 and FNE scores of female residents were significantly higher than those of male residents (respectively P=0.004 and P=0.049).

CONCLUSION

First-year anaesthesiology and critical care residents had low trait anxiety and FNE. HFS training increased their HR but not their BP. Their state anxiety also remained low. Several differences between individuals were noted, particularly between men and women.