The effect of clinical simulation assessment on stress and anxiety measures in emergency care students

Simulation, Flipped Classroom, and Reflective Dialogue in Socioemotional Training in End-of-Life Care: Perspectives of Nursing Students

The implementation of active methodologies in end-of-life education can play a crucial role in stimulating participatory learning and facilitating the acquisition of socioemotional competencies. An exploratory descriptive qualitative study was conducted to describe the students' perspective on the use of simulation, reflective dialogue, and the flipped classroom in an end-of-life education program. Undergraduate nursing students who had not yet begun their practicums were included. At the end of the training program, 4 focus groups were used. After the analysis, 3 themes and 32 categories emerged from the study. The themes included the contribution of the methodologies to learning, the characteristics that the methodology had to meet to be more effective, and motivational and emotional aspects triggered by the educational resources used. From the students' perspective, simulation, reflective dialogue, and flipped classroom enhance the conceptual learning process and facilitate students' socioemotional preparation to face this complex and challenging professional situation.

The effects of controlled acute psychological stress on serum cortisol and plasma metanephrine concentrations in healthy subjects

BACKGROUND

As cortisol and metanephrine are involved in the stress response, it is often recommended that individuals are relaxed at the time of venepuncture, however, evidence behind these recommendations is lacking. We investigated the effects of acute psychological stress on serum cortisol and plasma metanephrine concentrations in healthy individuals exposed to varying levels of psychological stress and compared these results to self-reported measures of stress.

METHODS

Ten medical students completed two medical in-person simulations (one low-complexity, one high-complexity) in a random order. At four times, participants completed the State-Trait Anxiety Inventory (STAI) and serum cortisol and plasma metanephrine/normetanephrine were tested.

RESULTS

Median (interquartile range) STAI prior to the low-complexity simulation was 44 (18) versus 33 (13) afterwards (P = 0.050). STAI prior to the high-complexity simulation was 33 (10) versus 48 (17) afterwards (P = 0.007). Cortisol prior to the low-complexity simulation was 272 nmol/L (115) versus 247 (115) afterwards (P = 0.333). Prior to the high-complexity simulation, cortisol was 246 (70) versus 261 (137) afterwards (P = 0.859). Metanephrine prior to the low-complexity simulation was 242 pmol/L (79) versus 247 (93) afterwards (P = 0.515). Metanephrine prior to the high-complexity simulation was 220 (81) versus 251 pmol/L (120) afterwards (P = 0.074). Normetanephrine prior to the low-complexity simulation was 593 pmol/L (247) versus 682 (281) afterwards (P = 0.047 for the difference). Normetanephrine prior to the high-complexity simulation was 696 (123) versus 705 pmol/L (224) afterwards (P = 0.169).

CONCLUSIONS

The trend in cortisol levels largely reflected changes in STAI. We outline some implications of these findings for current practice and future research.

The effect of assessor visibility on student stress and anxiety in emergency care simulation assessments

BACKGROUND

Simulation assessment can result in anxiety for students. These assessments involve being observed by assessors, so there is a significant socio-evaluative stress component which may cause greater anxiety if assessors are visible to students during assessments. The aim of this study was to determine the effect of assessor visibility on biological and physiological markers of stress and levels of anxiety experienced by pre-hospital emergency care students in a simulation assessment environment.

METHODS

A paired comparison, pre-post test research design was used with two conditions; an assessor visible condition with simulation assessors visible to students in the room and an assessor not visible condition with assessors not in the room but connected via video link. With a sample of 29 emergency care students anxiety was measured with the State-Trait Anxiety Inventory and stress was measured with salivary cortisol and heart rate variability (HRV).

RESULTS

Differences in state anxiety scores, HRV variables and salivary cortisol suggested lower stress and anxiety in the assessor visible group. Only heart rate was significantly different between the groups (p = 0.016), with a higher heart rate in the assessor not visible group.

CONCLUSIONS

Greater stress and anxiety may be experienced by students during emergency care simulation assessments when assessors are not visible to students.

Medical Students' Preferences on Practicing Intravenous Insertion on Each Other and Via Simulation

SUMMARY STATEMENT

Medical students have traditionally practiced painful procedures such as intravenous (IV) line insertion on each other. Recently, there has been more emphasis on learning through simulation. Our study investigated students' attitudes regarding IV line insertion training, focusing on their anxiety, expectation to learn empathy, learning preference, and litigiousness. A 24-question survey was taken regarding anxiety and empathy when learning IV placement on each other versus on mannequins.Many students believed that they could learn empathy skills and better appreciate patient discomfort by learning IV placement through person-based practice. However, students who reported feeling anxious about having a student practice IV placement on them believed they were less likely to learn empathy through having a student practice IV insertion on them. The preferred method of learning painful procedures, such as IV placement, may be through a combination of simulation and person-based practice to mitigate anxiety while also enhancing empathy skills.

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.

Untapped resource: the simulation-based healthcare environment as a means to study human stress

The effects of 'stress' within the healthcare professions are wide-reaching, not least of all within the field of simulation-based healthcare education. Whilst this popular method of experiential learning offers a 'safe space' for participants to develop their skillset, it also has a more surreptitious action; namely, the incubation of simulation-related stress. Currently, research concerning the complex relationship between stress, learning, and performance is ambiguous, leaving fertile ground for simulationists to debate what level of stress is appropriate for an optimised educational experience. In this narrative review, we examine the human response to stress and outline the various methods that have been used by researchers to measure stress in a quantifiable and standardised way. We then provide a brief overview of simulation-based healthcare education before describing why stress responses have been of interest to healthcare educationalists for some time. Finally, we outline how simulation education environments might provide an ideal environment for studying the human response to stress generally, with ramifications extending beyond the field of medical education.

Physiologic Fidelity as a Domain in Assessing Mixed Reality Trauma Simulation

INTRODUCTION

Mixed reality has been used in trauma and emergency medicine simulation for more than a decade. As mixed reality potential in trauma simulation continues to expand, so too does the need to validate it as a surrogate for real-life emergency scenarios. Validation of these simulations can occur by measuring fidelity, or the degree to which a computing system can reproduce real-world experiences. After performing a literature review, we determined that most fidelity assessments of trauma and emergency simulations focus on how the user subjectively experiences the simulation. Although subjective user assessment is an important component of determining fidelity, we pose an introductory three-part framework that may assess mixed reality trauma simulation more adequately.

MATERIALS AND METHODS

A literature review was conducted using Google Scholar, PubMed, and the Uniformed Services University PowerER search database. Relevant articles were assessed to identify how studies measured fidelity in trauma simulation. We then designed the three-part framework to aid researchers in assessing the fidelity of mixed reality trauma simulations.

RESULTS

The domains we determined to best assess mixed reality emergency simulation are as follows:1. Continue assessing fidelity via subjective user assessments. This allows the researcher to know how real the simulation looked and felt to the user based on their individual report.2. Determine whether the trauma simulation changes the medical decision-making capacity of the user. If the user's decision-making capacity changes with a stress-inducing trauma simulation versus a non-stress-inducing simulation, then the stress-inducing trauma environment would be approaching greater fidelity.3. Study the domain of our newly proposed concept: physiologic fidelity. We define physiologic fidelity as the degree to which the simulation elicits a measurable, autonomic response independent of observed emotion or perceived affect. Recreating objective autonomic arousal may be the best way to ensure a trauma simulation reaches fidelity.

CONCLUSION

We propose a methodology to assess mixed reality trauma simulation fidelity. Once fidelity is more fully known to the researcher and the simulation user, adjustments can be made to approach reality more closely. Improved simulators may enrich the preparedness of both junior and senior learners for real-life emergencies. We believe assessing the three domains using the Wide Area Virtual Experience at the Val G. Hemming simulation center in Bethesda, MD, will validate mixed reality-trauma simulators as invaluable surrogates for real-life emergency scenarios and ultimately contribute to improved clinical outcomes for clinicians and their patients.

Use of global rating scales and checklists in clinical simulation-based assessments: a protocol for a scoping review

INTRODUCTION

Assessment in health sciences education remains a hotly debated topic, with measures of competency and how to determine them in simulation-based assessments enjoying much of the focus. Global rating scales (GRS) and checklists are widely used within simulation-based education but there is a question regarding how the two strategies are used within clinical simulation assessment. The aim of this proposed scoping review is to explore, map and summarise the nature, range and extent of published literature available relating to the use of GRS and checklists in clinical simulation-based assessment.

METHODS

We will follow the methodological frameworks and updates described by Arksey and O'Malley, Levac, Colquhoun and O'Brien, and Peters, Marnie and Tricco et al and will report using the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). We will search PubMed, CINAHL, ERIC, Cochrane Library, Scopus, EBSCO, ScienceDirect, Web of Science, the DOAJ and several sources of grey literature. We will be including all identified sources published in English after 1 January 2010 that relate to the use of GRS and/or checklists in clinical simulation-based assessments. The planned search will be conducted from 6 February 2023 to 20 February 2023.

ETHICS AND DISSEMINATION

An ethical waiver was received from a registered research ethics committee and findings will be disseminated through publications. The overview of literature the produced will help to identify knowledge gaps and inform future research on the use of GRS and checklists in clinical simulation-based assessments. This information will be valuable and useful for all stakeholders that are interested in clinical simulation-based assessments.

Effects of Blended Simulation on Nursing Students' Critical Thinking Skills: A Quantitative Study

Introduction

Critical thinking is regarded as imperative to healthcare quality and patient outcomes; therefore, effective strategies in nursing education are required to promote students' critical thinking abilities, leading to their success in clinical work. Accordingly, simulation-based education has been suggested as a measure for achieving this goal.

Objective

The aim of this study was to explore whether a nursing education course with blended simulation activities (hands-on simulations with high-fidelity manikins and a web-based interactive simulation program) could increase nursing students' critical thinking skills.

Method

A quasiexperimental, one-group pretest and post-test design was utilized. Data were collected through premeasurement and postmeasurement using a critical thinking questionnaire and were analyzed using paired sample t-tests, independent sample t-tests, and the nonparametric Wilcoxon signed-rank test. The effect size was calculated using Cohen's d formula.

Results

Sixty-one nursing students (57 women and four men, mean age 30 years) participated in the study. Findings of the paired sample t-test showed a significantly higher mean score for posteducation than pre-education, indicating a significant change in nurses' critical thinking capabilities (p < .001). The results for Cohen's d formula ( - 0.87) of the mean scores between pre-education and posteducation indicated a large effect size. The Wilcoxon signed-rank test also showed a statistically significant increase in the students' critical thinking abilities between pre-education and posteducation measures (p < .001). No statistically significant differences were found in the mean score according to age or sex.

Conclusion

This study concluded that blended simulation-based education can increase nursing students' critical thinking capabilities. As a result, this study builds on the use of simulation as a measure for developing and promoting critical thinking abilities during nursing education.

A Systematic Review of Heart Rate Variability as a Measure of Stress in Medical Professionals

Understanding the physiological effects of responding to crises is a critical component in understanding how to manage and prepare medical professionals to be crisis responders. Heart rate variability (HRV) is the variation in rate between a succession of R-R intervals. This variation is not only affected by physiological processes such as respiration or metabolic rate but is also directly controlled by the autonomic nervous system. As such, heart rate variability has been proposed as a noninvasive tool to measure the physiological stress response. The aim of this systematic review is to consolidate heart rate variability literature in the context of medical emergencies to determine if heart rate variability changes predictably from baseline when responding to medical crises. This may demonstrate utility as an objective, noninvasive measure of stress response. A systematic literature review of six databases yielded 413 articles, 17 of which met our inclusion criteria of being written in English, measuring HRV in healthcare providers, and measuring HRV in real or simulated medical resuscitations or procedures. Articles were then analyzed using the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) scoring system. Out of the 17 articles reviewed, 11 demonstrated statistically significant results showing heart rate variability responding in a predictable manner to stress. Three articles utilized a medical simulation as the stressor, six used medical procedures, and eight used medical emergencies encountered during clinical work. Overall, a predictable trend in heart rate variability metrics of standard deviation from the mean value of normal-to-normal (N-N) intervals (SDNN), root mean square of the successive differences (RMSSD), mean number of times per time interval in which the change in successive normal sinus (N-N) intervals exceeds 50 ms (PNN50), low frequency % (LF%), and low-frequency-to-high-frequency ratio (LF/HF) was observed when responding to stress. This systematic literature review showed that heart rate variability among healthcare providers responding to stressful scenarios follows a predictable pattern of change and expands our understanding of the physiology of stress in healthcare providers. This review supports the use of HRV to monitor stress during high-fidelity simulation to ensure that appropriate physiological arousal is achieved during the training of medical personnel.

Mindfulness for stress and anxiety management in nursing students in a clinical simulation: A quasi-experimental study

AIM

To determine the efficacy of an online mindfulness intervention in reducing anxiety and stress levels in nursing students during clinical simulations.

BACKGROUND

Clinical simulation as a learning strategy has many benefits but the high levels of stress and anxiety it produces in participants can compromise learning, motivation or performance.

DESIGN

A quasi-experimental study with a non-equivalent control group design is presented. Forty-two undergraduate nursing students from a natural group were divided into: an experimental group (n = 21) and a control group (n = 21).

METHODS

Before conducting a clinical simulation, the experimental group followed a 10-day intensive online mindfulness intervention. All students received the same information and training. Instruments used were: Self-administered Analogue Stress Scale, State-Trait Anxiety Inventory and Five Facet Mindfulness Questionnaire. In addition, physiological data (blood pressure and heart rate) were collected at baseline, pre-briefing and debriefing.

RESULTS

Physiological variables increased in the prebriefing phase but remained statistically significantly lower in the experimental group (diastolic blood pressure p = .032 and heart rate p = .048). Levels of stress (p = .029) and anxiety (p = .016) were also managed better. Both groups in the debriefing session showed a statistically significant decrease in the different physiological variables, stress and anxiety. No changes in mindfulness were observed.

CONCLUSIONS

The clinical simulation is indicated to generate stress and anxiety in nursing students. Therefore, measures must be adopted to control it. The intensive online mindfulness intervention proposed in this study reduced physiological parameters, stress and anxiety in the clinical simulation.

The Impact on the Stress-Associated Autonomic Response of Physiotherapy Students Receiving Interferential Current in an Electrotherapy Training Session

Electrical currents are didactic contents widely applied in the training of physiotherapy students, but the treatment is considered a stressful situation for both the patient who receives it and the student who applies it. The aim of this study was to evaluate the stress-associated autonomic response of physiotherapy students receiving interferential current by measuring and analysing heart rate variability. An observational case-control study was conducted. Ninety healthy male volunteers, all physiotherapy degree students, were enrolled while attending laboratory practice during the 2020-2021 academic year. Participants were randomly allocated to a sham electrotherapy group (44 subjects), in which heart rate variability was recorded for 10 min, both at rest and during the application of sham technique on the lower back (10 min), and an electrotherapy group (46 subjects), applying the same procedure with the electrical current flowing. Outcome measures included baseline (seated position) and postintervention (prone position) time domain parameter, diameters of the Poincaré plot 1 and 2, stress score, and sympathetic/parasympathetic ratio. The sham electrotherapy group exhibited significant increases in time domain parameter (p = 0.027) and diameters of the Poincaré plot 1 (p = 0.032), with a small effect size (d ≤ 0.5). The electrotherapy group exhibited significant increases in time domain parameter and diameters of the Poincaré plot 1 and 2 (p < 0.001) and decreases in the stress score and sympathetic/parasympathetic ratio (p < 0.001), with a large effect size (d > 0.8) other than for the time domain parameter (d = 0.42), indicating increased parasympathetic and decreased sympathetic activity. After interventions, there were significant differences between groups in diameters of the Poincaré plot 2 (p < 0.001), stress score (p = 0.01) and sympathetic/parasympathetic ratio (p = 0.003), with moderate effect size (d > 0.5). The application of the interferential current technique produces stress-associated autonomic response characterized by greater parasympathetic activity and decreased sympathetic activity. Further studies are needed to determine possible adverse effects.

Pharmacy students' perceptions of an oncology pharmacy simulation

BACKGROUND AND PURPOSE

Cancer is on the rise both globally and in South Africa, with an estimated 70% increase in incidence in Sub-Saharan Africa by 2030. While oncology pharmacy is a highly specialized field of practice, there is currently no formal certification for oncology pharmacists in South Africa.

EDUCATIONAL ACTIVITY AND SETTING

To standardise the way in which oncology pharmacy is practiced within the country, the first-ever simulation-based oncology admixing training for pharmacy students in South Africa was developed at the University of the Witwatersrand. Following the simulation, a survey was conducted to determine the participants' perceptions of the simulation. Current and past pharmacy students were invited to complete a questionnaire. Data were collected through a self-administered cross-sectional REDCap (Research Electronic Data Capture) questionnaire using a Likert-like scale to determine the agreed with statements related to the simulation.

FINDINGS

A total of 81 participants completed the questionnaire. Participants provided favorable feedback related to the simulation's benefit, quality, and learning experience.

SUMMARY

Based on the perceptions of the participants, the purpose of the simulation exercise was achieved.

Use of simulation to teach in the operating room: don't Let the COVID-19 pandemic to interrupt education an observational clinical trial

Background

Simulation-based education has become the most important part of resident training in anesthesiology, especially during the pandemic. It allows learning the skills and the management of different situations without putting residents in risk of contamination, considering COVID-19 is highly contagious. The hypothesis was that simulation is still associated with improvement of knowledge acquisitions despite the context of the COVID-19 pandemic.

Methods

Residents of anesthesiology and intensive care subjected to an anaphylaxis simulation scenario. Their knowledge levels were assessed by true/false questions before and one month after the simulation session. The STAI test was used to measure anxiety levels before and after the scenario. Data were analyzed statistically using Wilcoxon and McNemar tests.

Results

Junior residents (< 2 years) received significantly higher scores in post-training theoretical tests compared to their pre-training scores (79.2 ± 9.6, 84.5 ± 8.2, p = 0.002, n = 21). There was no difference between pre- and post-test scores of seniors (80.2 ± 9, 81.8 ± 10.4, p = 0.3). Pre- and post-anxiety inventory scores were nearly the same and both were in the moderate group (39.8 ± 10.1, 39.3 ± 12.1, p = 0.8).

Conclusion

Simulation-based education improved the knowledge levels of the residents without raising anxiety levels. Thus, simulation-based training showed its value as an important tool of education during the pandemic, which needs to be further popularized for training at all institutions. Enlightening medical educators about this accomplished teaching method may lead to improved quality of medical education in developing countries and reshape how tomorrow's doctors are trained during pandemics.

Experimental Study on the Evaluation and Influencing Factors on Individual's Emergency Escape Capability in Subway Fire

Studying an individual’s emergency escape capability and its influencing factors is of great practical significance for evacuation and escape in subway emergencies. Taking Zhengzhou Zijing Mountain Subway station as the prototype, and using VR technology, a virtual subway fire escape scene was built. Combined with the total escape time, the total contact time with fire, and the total contact time with smoke, it proposed a calculation formula on emergency escape capability. A total of 34 participants with equal gender distribution were recruited to carry out the virtual subway fire escape experiment, and participants’ physiological data (heart rate variability, skin conductance) were real-time recorded by ErgoLAB V3.0 throughout the whole experiment. The emergency escape capability of each participant was evaluated quantitatively, and the related influencing factors were analyzed. The results show that for the age ranges (19–22 years old) in the experiment, the emergency escape capability of women is significantly lower than that of men (p < 0.05); although there is no significance in emergency escape capability in DISC personality types (p > 0.05), the mean emergency escape capability of people with influence personality type is the worst, and that of people with compliance type is the best; during virtual fire escape vs. baseline, Mean_SC and Mean_HR both increased very significantly (all p < 0.01), and participants were under stress during their virtual fire escape. There is a significant negative correlation between emergency escape capability and LF_increase_rate (p < 0.05), and a remarkably significant negative correlation between emergency escape capability and LF/HF_increase_rate (p < 0.01); the greater the increase rate of LF or LF/HF, the smaller the emergency escape capability, with excessive stress probably not being conducive to emergency escape. There is a very significant negative correlation between an individual’s emergency escape capability and the degree of familiarity with the Zijing Mountain subway station (p < 0.01). The findings provide references and suggestions on the emergency management and emergency evacuation for government and subway departments.