Abstract
BackgroundHigh-fidelity patient simulation has been praised for its ability to recreate lifelike training conditions. The degree to which high fidelity simulation elicits acute emotional and physiologic stress among participants – and the influence of acute stress on clinical performance in the simulation setting – remain areas of active exploration. We examined the relationship between residents’ self-reported anxiety and a proxy of physiologic stress (heart rate) as well as their clinical performance in a simulation exam using a validated assessment of non-technical skills, the Ottawa Crisis Resource Management Global Rating Scale (Ottawa GRS).MethodsThis was a prospective observational cohort study of emergency medicine residents at a single academic center. Participants managed a simulated clinical encounter. Anxiety was assessed using a pre- and post-simulation survey, and continuous cardiac monitoring was performed on each participant during the scenario. Performance in the simulation scenario was graded by faculty raters using a critical actions checklist and the Ottawa GRS instrument.ResultsData collection occurred during the 2011 academic year. Of 40 eligible residents, 34 were included in the analysis. The median baseline heart rate for participants was 70 beats per minute (IQR: 62 – 78). During the simulation, the median maximum heart rate was 140 beats per minute (IQR: 137 – 151). The median minimum heart rate during simulation was 81 beats per minute (IQR: 72 – 92), and mean heart rate was 117 beats per minute (95% CI: 111 – 123). Pre- and post-simulation anxiety scores were equal (mean 3.3, IQR: 3 to 4). The minimum and maximum Overall Ottawa GRS scores were 2.33 and 6.67, respectively. The median Overall score was 5.63 (IQR: 5.0 to 6.0). Of the candidate predictors of Overall performance in a multivariate logistic regression model, only PGY status showed statistical significance (P = 0.02).ConclusionsSimulation is associated with physiologic stress, and heart rate elevation alone correlates poorly with both perceived stress and performance. Non-technical performance in the simulation setting may be more closely tied to one’s level of clinical experience than to perceived or actual stress.
Highlights
High-fidelity patient simulation has been praised for its ability to recreate lifelike training conditions
The purpose of this study was to identify candidate factors that may be predictive of overall crisis resource management (CRM) performance as measured by the Ottawa Global Rating Scale (GRS), and to determine the relationship between physiologic stress and clinical performance using the percentage of critical actions performed in each simulation scenario
The level of difficulty of the simulation cases is stratified by post-graduate year: PGY-1 residents manage an ACLS-themed case involving a patient in cardiac arrest; PGY-2 residents manage a patient with sepsis and respiratory failure; and PGY-3 residents manage a case involving a critically ill polytrauma patient (Additional files 1, 2 and 3)
Summary
High-fidelity patient simulation has been praised for its ability to recreate lifelike training conditions. The degree to which high fidelity simulation elicits acute emotional and physiologic stress among participants – and the influence of acute stress on clinical performance in the simulation setting – remain areas of active exploration. Experiential learning requires some degree of engagement and stress; DeMaria and colleagues [6] found that a simulation scenario that induced anxiety led to better performance and retention of ACLS skills among medical students than one that did not. Hunziker et al [8] found that medical students performing CPR in a simulation exercise demonstrated high levels of emotional overload and significantly poorer clinical performance. Two additional studies by LeBlanc et al [9,10] found that paramedics exposed to high levels of acute stress during simulation scenarios were more likely to commit errors in communication and medication dosing
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