Stress in Simulation-Based Resuscitation Education—Seeking Objective Measures to Spit and Swallow?*

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Resuscitation of a pulseless newborn is a stressful event for healthcare providers. Performance of the cognitive, technical, and behavioral skills during resuscitation is very challenging, with great potential for cognitive and task overload. Strong emotional responses are common and have been said to “hijack the amygdala,” causing some team leaders to “freeze” or dysfunction. Simulation-based training has been used for decades to enhance sharp end provider performance during intense resuscitations. Simulation events are designed to replicate these stressful events as a part of training. Therefore, to some extent, emotional responses during simulation are expected and desirable, and often considered as a barometer of fidelity (realism) of the simulation experience (1). Existing literature supports that learning environments, such as simulation, that invoke appropriate stress serve to enhance trainees’ learning ability, but that environments that either do not evoke enough stress or evoke too much stress might be detrimental (2). To optimize learning, it would be ideal to titrate the scenario realism and complexity (cognitive and emotional load) to achieve the appropriate stress level of trainees. The current challenge, however, is that simulation educators depend solely on their perception to gauge participants’ stress level rather than an objective measurement.
In this issue of Pediatric Critical Care Medicine, Lizotte et al (3) reported their prospective study to evaluate the trainees stress level during simulated neonatal resuscitation. They randomized pediatric trainees (approximately 2/3 were first and second year residents) into two parallel groups: the first group participated in a simulation scenario with a pulseless newborn who remained pulseless despite resuscitative efforts, and the second group with a pulseless newborn who responded to resuscitative efforts. Their outcome included a physiologic evaluation of stress level measured by saliva cortisol level (spit cortisol) immediately before simulation and after the first simulation scenario before debriefing, compared with baseline cortisol levels measured on a different day without simulation activity. They also used a self-reported stress level measurement on a 1–10 Likert scale (10: highest). On the self-reported scale, the participants reported a moderate to high stress level with the majority of responses within 5–9, demonstrating that the simulation was effective in evoking self-reported stress of participants. When looking at the physiologic marker of stress, they found that the salivary cortisol level was higher in specimens obtained immediately before simulation compared with baseline, suggesting that the prospect of participating in simulation was stress provoking in itself. The investigators also found that the salivary cortisol level after participating in the simulation scenario was significantly higher than those immediately before simulation, implying stress also occurred during participation in the simulated resuscitation. These findings are consistent with a previous simulation study by Bong et al (4), which evaluated the change in saliva cortisol level in gastroenterology physicians during simulated emergencies. It is also noteworthy that the perceived stress level and the increase in cortisol levels were not significantly correlated (p = 0.09).
There is still great debate in the simulation education community about simulated death in the learning environment and the value on learning. This study is notable in that it attempted to evaluate the impact of simulated death on stress/anxiety in the participants. They found that there was no difference between two groups in salivary cortisol levels despite different scenario progression (i.e., death vs resuscitation responder). The authors previously published the perception of participants regarding simulated death from this study cohort, which was overall supportive (5). There is currently a paucity of evidence how death in simulation scenarios affect the learning of participants.

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