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Purpose Physicians are expected to provide compassionate, error-free care while navigating systemic challenges and organizational demands. Many are burning out. While organizations are scrambling to address the burnout crisis, physicians often resist interventions aimed at enhancing their wellness and building their resilience. The purpose of this research was to empirically study this phenomenon. Method Constructivist grounded theory was used to inform the iterative data collection and analysis process. In spring 2018, 22 faculty physicians working in Canada participated in semistructured interviews to discuss their experiences of wellness and burnout, their perceptions of wellness initiatives, and how their experiences and perceptions influence their uptake of the rapidly proliferating strategies aimed at nurturing their resilience. Themes were identified using constant comparative analysis. Results Participants suggested that the values of compassion espoused by health care organizations do not extend to physicians, and they described feeling dehumanized by professional values steeped in an invincibility myth in which physicians are expected to be "superhuman" and "sacrifice everything" for medicine. Participants described that professional values and organizational norms impeded work-life balance, hindered personal and professional fulfillment, and discouraged disclosure of struggles. In turn, participants seemed to resist wellness and resilience-building interventions focused on fixing individuals rather than broader systemic, organizational, and professional issues. Participants perceived that efforts aimed at building individual resilience are futile without changes in professional values and sustained organizational support. Conclusions Findings suggest that professional and organizational norms and expectations trigger feelings of dehumanization for some physicians. These feelings likely exacerbate burnout and may partly explain physicians' resistance to resilience-building strategies. Mitigating burnout and developing and sustaining a resilient physician workforce will require both individual resistance to problematic professional values and an institutional commitment to creating a culture of compassion for patients and physicians alike.

Burnout is a growing concern, with significant negative consequences for physicians and patient care. Burnout is negatively associated with physician empathy, while resilience may be a protective factor against the development of burnout but few studies have examined all three constructs in the same cohort. Understanding the associations between these constructs could aid in the development of interventions for physicians experiencing burnout and improve the delivery of compassionate care. We conducted a cross-sectional survey to determine levels of burnout, empathy and resilience in a sample of academic physicians and investigate the relationships between these variables. Validated scales were administered online to measure burnout (Maslach Burnout Inventory - Human Services Survey, MBI-HSS), empathy (Jefferson Scale of Empathy - Physicians/Health Professions Version, JSE) and resilience (Connor-Davidson Resilience Scale, CD-RISC). Descriptive statistics, correlation coefficients, and group comparisons were examined. Eighty-three physicians completed the JSE and CD-RISC, while a subset of 49 physicians also completed the MBI-HSS. Response rates were 31.9% and 18.8%, respectively. High burnout was reported by 49% of the sample. Physicians with high burnout reported lower levels of resilience than those who were not burnt-out. No differences in levels of empathy were observed between these two groups. Older physicians (>45 years) reported higher resilience scores than younger physicians. Resilience and empathy were significantly positively correlated. The reported rate of physician burnout in this sample of academic physicians is concerning, with burnout associated with lower levels of resilience. Further research is required to explore the relationship between physician age and resilience, the impact of resilience-building interventions on burnout and empathy in physicians, and how modifying these variables influences the delivery of compassionate care for patients.

Simulation-based education requires significant time and resources. As such, educators are often called on to provide evidence that their program or activities accomplish the desired goals and return on the investment. This is an essential, but often under-recognized, aspect of running a simulation program. Program evaluation is conducted to determine whether a program meets set goals; leads to the desired outcomes; and how the program was implemented [1].

Simulation is a pedagogical method known to be a generator of stress, that could be influenced by previous stressful experiences.The purpose of this study was to determine the impact of previous experience with a clinical critical event on the stress experienced by nursing students during simulation session of critical events, and on the stress experienced during clinical critical events subsequent to the training.Observational case-control study.Four critical event scenarios were created using full-scale simulation.Two hundred and fifteen undergraduate nursing students of semester four. The control group (n = 112) consisted of learners who had not previously experienced a critical event. The prior exposure group (n = 103) consisted of learners who had experienced a critical event prior to the course.Stress levels were assessed using the self-report stress numerical rating scale-11.There was no significant difference in the level of stress between the prior exposure group and the control group before, during or expected after the simulation session. A significant decrease in stress was observed in both groups from before the course to during the session (p 0.05) and expected after the session (p 0.05). There was no significant difference between the expected post-session stress level and the stress levels reported four months after the training (p = 0.966). At four months, there was no significant difference in stress levels between the groups (p = 0.212).The prior experience of a clinical critical event before a simulation course did not influence their reported stress level during the simulation session. Conversely, simulation-based training of critical situations appears to reduce the level of self-assessed stress during critical events in clinical practice after the training.

IntroductionThe proportion of older acute care physicians (ACPs) has been steadily increasing. Ageing is associated with physiological changes and prospective research investigating how such age-related physiological changes affect clinical performance, including crisis resource management (CRM) skills, is lacking. There is a gap in the literature on whether physician’s age influences baseline CRM performance and also learning from simulation. We aim to investigate whether ageing is associated with baseline CRM skills of ACPs (emergency, critical care and anaesthesia) using simulated crisis scenarios and to assess whether ageing influences learning from simulation-based education.Methods and analysisThis is a prospective cohort multicentre study recruiting ACPs from the Universities of Toronto and Ottawa, Canada. Each participant will manage an advanced cardiovascular life support crisis-simulated scenario (pretest) and then be debriefed on their CRM skills. They will then manage another simulated crisis scenario (immediate post-test). Three months after, participants will return to manage a third simulated crisis scenario (retention post-test). The relationship between biological age and chronological age will be assessed by measuring the participants CRM skills and their ability to learn from high-fidelity simulation.Ethics and disseminationThis protocol was approved by Sunnybrook Health Sciences Centre Research Ethics Board (REB Number 140–2015) and the Ottawa Health Science Network Research Ethics Board (#20150173–01H). The results will be disseminated in a peer-reviewed journal and at scientific meetings.Trial registration numberNCT02683447.

Simulation is now commonly used in health care education, and a growing body of evidence supports its positive impact on learning. However, simulation-based medical education (SBME) involves a range of modalities, instructional methods, and presentations associated with different advantages and limitations. This review aims at better understanding the nature of SBME, its theoretic and proven benefits, its delivery, and the challenges posed by SBME. Areas requiring further research and development are also discussed.

Purpose The goal of this study was to better understand how clinical supervisors integrate teaching interactions with medical trainees into 2 types of clinical activities in the critical care setting: multidisciplinary rounds and medical crises. Methods We conducted a qualitative, observational study based on an ethnographic approach. We observed the teaching interactions among clinical supervisors and medical trainees during 12 multidisciplinary rounds and 74 medical crises in 2 academic hospitals. Grounded theory methods (theoretical sampling and saturation, inductive thematic coding, and constant comparison) were used to analyze data. Results Two models of integration of teaching interactions into clinical activities are described: the in series model, typical of multidisciplinary rounds and characterized by well-structured learning bubbles uninterrupted by patient care, and the in parallel model, common during medical crises and involving multiple, short learning flashes intricately related to and frequently interrupted by patient care. By adopting a model over the other, supervisors appeared to adapt to 2 contexts that differed in terms of priority, supervisor's understanding of events, and social context of interactions. Each model presented complementary opportunities and limitations for learning. Conclusions Modern views of medical apprenticeship and clinical teaching need to take into account the specific clinical context in which learning occurs. Teaching interactions that differ in structure and content in response to changing clinical circumstances could impact learning in unique ways. Learning outcomes resulting from different models of integration of teaching into clinical activities need to be further explored.

Suicide risk assessment is a critical component of mental health practice for which the stakes are high and the outcomes uncertain. This research examines the consistency with which clinicians make determinations of suicide risk and factors influencing clinical confidence. Seventy-one social workers interviewed two standardized patients performing in scenarios depicting suicidal ideation, judged whether the patient required hospitalization, and completed standardized suicide risk assessment measures. Self-ratings and qualitative interviews explored participants’ confidence in their judgment of risk. Participants had highly divergent views regarding whether or not the risk of suicide was sufficiently high to require hospitalization. However, regardless of the ultimate decision reached, participants were equally confident when recommending either clinical course of action. The variation in risk assessment appraisals in this study, despite at times high rates of confidence in risk appraisals, speaks ...

Progressive trainee autonomy is considered essential for clinical learning, but potentially harmful for patients. How clinical supervisors and medical trainees establish progressive levels of autonomy in acute care environments without compromising patient safety is largely unknown.To explore how bedside interactions among supervisors and trainees relate to trainee involvement in patient care and to clinical oversight.We conducted a qualitative study based on constructivist grounded theory methodology. We used participant observation for our data collection. We observed the overt teaching interactions among trainees and staff physicians in the critical care units of two university-affiliated hospitals during 74 acute care episodes. Our analysis led to the elaboration of a theoretical model of clinical supervision.A model of interactive clinical supervision is proposed on the basis of three themes: engaging without enactment, sharing care with support, and caring independently with feedback. Each theme regroups different teaching interactions. Engaging in monologues and dialogues about patient care and facilitating hands-off care provision involved progressive levels of trainee involvement without risk for patients. Facilitating hands-on provision of care and providing support-in-action encouraged further trainee involvement with limited risks for patients. Providing feedback-on-action created additional learning opportunities based on trainee independent involvement in clinical activities.Engaging in teaching interactions during acute care episodes allows trainees to exercise progressive autonomy and supervisors to provide adequate clinical oversight. Our model of interactive clinical supervision can inform faculty development initiatives. Learning outcomes resulting from different levels of trainee autonomy should be further explored.

Professional judgment in complex clinical situations such as the assessment of suicide risk encompasses a multifaceted cognitive understanding of the substantive issues, technical expertise, and emotional awareness. This experimental design study investigated the degree to which the previous work-related experiences of clinicians and their preexisting emotional state influence professional judgment regarding acute risk in patients presenting with suicidal ideation. Experienced social workers and social work students conducted suicide risk assessments on 2 standardized patients performing in scenarios constructed to depict individuals presenting with suicidal ideation. This study revealed significant variations in clinical judgments of practitioners assessing suicide risk. While scores on standardized risk assessment measures were the strongest predictor of judgments regarding the need for hospitalization to ensure the safety of the patient, other influences included clinician age and levels of posttraumatic stress symptoms. Mental health clinicians and organizations that employ them should be aware of possible individual influences on professional judgments related to suicide risk.

Despite research identifying high levels of stress and traumatic stress symptoms among those in the emergency services, the impact of these symptoms on performance and hence public safety remains uncertain. This review paper discusses a program of research that has examined the effects of prior critical incident exposure, acute stress, and current post-traumatic symptoms on the performance and decision-making during an acutely stressful event among police officers, police communicators, paramedics and child protection workers. Four studies, using simulation methods involving video simulators, human-patient simulators, and/or standardized patients, examined the performance of emergency workers in typical workplace situations related to their individual profession. Results varied according to level of acuity of stress and the nature of performance and decision-making. There was no evidence that PTSD had a direct impact on global performance on tasks for which emergency responders are highly trained. However, PTSD was associated with assessment of risk in situations that required professional judgement. Further, individuals experiencing PTSD symptoms reported higher levels of acute stress when faced with high acuity situations. Acute stress in these studies was associated with performance deficits on complex cognitive tasks, verbal memory impairment and heightened assessment of risk.

Contains fulltext : 175727.pdf (Publisher’s version ) (Open Access) BACKGROUND: Simulation-based medical education (SBME) has traditionally been conducted as off-site simulation in simulation centres. Some hospital departments also provide off-site simulation using in-house training room(s) set up for simulation away from the clinical setting, and these activities are called in-house training. In-house training facilities can be part of hospital departments and resemble to some extent simulation centres but often have less technical equipment. In situ simulation, introduced over the past decade, mainly comprises of team-based activities and occurs in patient care units with healthcare professionals in their own working environment. Thus, this intentional blend of simulation and real working environments means that in situ simulation brings simulation to the real working environment and provides training where people work. In situ simulation can be either announced or unannounced, the latter also known as a drill. This article presents and discusses the design of SBME and the advantage and disadvantage of the different simulation settings, such as training in simulation-centres, in-house simulations in hospital departments, announced or unannounced in situ simulations. DISCUSSION: Non-randomised studies argue that in situ simulation is more effective for educational purposes than other types of simulation settings. Conversely, the few comparison studies that exist, either randomised or retrospective, show that choice of setting does not seem to influence individual or team learning. However, hospital department-based simulations, such as in-house simulation and in situ simulation, lead to a gain in organisational learning. To our knowledge no studies have compared announced and unannounced in situ simulation. The literature suggests some improved organisational learning from unannounced in situ simulation; however, unannounced in situ simulation was also found to be challenging to plan and conduct, and more stressful among participants. The importance of setting, context and fidelity are discussed. Based on the current limited research we suggest that choice of setting for simulations does not seem to influence individual and team learning. Department-based local simulation, such as simulation in-house and especially in situ simulation, leads to gains in organisational learning. The overall objectives of simulation-based education and factors such as feasibility can help determine choice of simulation setting.

Clinical supervisors fulfill a dual responsibility towards patient care and learning during clinical activities. Assuming such roles in today's clinical environments may be challenging. Acute care environments present unique learning opportunities for medical trainees, as well as specific challenges. The goal of this paper was to better understand the specific contexts in which overt teaching interactions occurred in acute care environments. We conducted a naturalistic observational study based on constructivist grounded theory methodology. Using participant observation, we collected data on the teaching interactions occurring between clinical supervisors and medical trainees during 74 acute care episodes in the critical care unit of two academic centers, in Toronto, Canada. Three themes contributed to a better understanding of the conditions in which overt teaching interactions among trainees and clinical supervisors occurred during acute care episodes: seizing emergent learning opportunities, coming up against challenging conditions, and creating learning momentum. Our findings illustrate how overt learning opportunities emerged from certain clinical situations and how clinical supervisors and trainees could purposefully modify unfavorable learning conditions. None of the acute care episodes encountered in the critical care environment represented ideal conditions for learning. Yet, clinical supervisors and trainees succeeded in engaging in overt teaching interactions during many episodes. The educational value of these overt teaching interactions should be further explored, as well as the impact of interventions aimed at increasing their use in acute care environments.

Healthcare practice and education are highly emotional endeavors. While this is recognized by educators and researchers seeking to develop interventions aimed at improving wellness in health professionals and at providing them with skills to deal with emotional interpersonal situations, the field of health professions education has largely ignored the role that emotions play on cognitive processes. The purpose of this review is to provide an introduction to the broader field of emotions, with the goal of better understanding the integral relationship between emotions and cognitive processes. Individuals, at any given time, are in an emotional state. This emotional state influences how they perceive the world around them, what they recall from it, as well as the decisions they make. Rather than treating emotions as undesirable forces that wreak havoc on the rational being, the field of health professions education could be enriched by a greater understanding of how these emotions can shape cognitive processes in increasingly predictable ways.

Medical trainees have identified stress as an important contributor to their medical errors in acute care environments.The objective of this study was to determine if the addition of acute stressors to simulated resuscitation scenarios would impact on residents' simulated clinical performance.Fifty-four residents completed a control and a high-stress simulated scenario on separate visits. Stress measures were collected before and after scenarios. Two assessors independently evaluated residents' videotaped performance.Both control and high-stress scenarios triggered significant stress responses among participants; however, stress responses were not significantly different between control and high-stress conditions. No difference in performance was found between control and high-stress conditions (F value = 2.84, p = .098).Residents exposed to simulated resuscitation scenarios experienced significant stress responses irrespective of the presence of acute stressors during these scenarios. This anticipatory stressful response could impact on resident learning and performance and should be further explored.

Objectives: Closer supervision of residents’ clinical activities has been promoted to improve patient safety, but may additionally affect resident participation in patient care and learning. The objective of this study was to determine the effects of closer supervision on patient care, resident participation, and the development of resident ability to care independently for critically ill patients during simulated scenarios. Design: This quantitative study represents a component of a larger mixed-methods study. Residents were randomized to one of three levels of supervision, defined by the physical proximity of the supervisor (distant, immediately available, and direct). Each resident completed a simulation scenario under the supervision of a critical care fellow, immediately followed by a modified scenario of similar content without supervision. Setting: The simulation center of a tertiary, university-affiliated academic center in a large urban city. Subjects: Fifty-three residents completing a critical care rotation and 24 critical care fellows were recruited between April 2009 and June 2010. Interventions None. Measurements and Main Results: During the supervised scenarios, lower team performance checklist scores were obtained for distant supervision compared with immediately available and direct supervision (mean [SD], direct: 72% [12%] vs immediately available: 77% [10%] vs distant: 61% [11%]; p = 0.0013). The percentage of checklist items completed by the residents themselves was significantly lower during direct supervision (median [interquartile range], direct: 40% [21%] vs immediately available: 58% [16%] vs distant: 55% [11%]; p = 0.005). During unsupervised scenarios, no significant differences were found on the outcome measures. Conclusions: Care delivered in the presence of senior supervising physicians was more comprehensive than care delivered without access to a bedside supervisor, but was associated with lower resident participation. However, subsequent resident performance during unsupervised scenarios was not adversely affected. Direct supervision of residents leads to improved care process and does not diminish the subsequent ability of residents to function independently.

The objective of this study was to seek validity evidence for simulation-based assessments (SBA) of paramedics by asking to what extent the measurements obtained in SBA of clinical competence are associated with measurements obtained in actual paramedic contexts, with real patients.This prospective observational study involved analyzing the assessment of paramedic trainees at the entry-to-practice level in both simulation- and workplace-based settings. The SBA followed an OSCE structure involving full clinical cases from initial patient contact to transport or transfer of care. The workplace-based assessment (WBA) involved rating samples of clinical performance during real clinical encounters while assigned to an emergency medical service. For each candidate, both assessments were completed during a 3-week period at the end of their training. Raters in the SBA and WBA settings used the same paramedic-specific seven-dimension global rating scale. Reliability was calculated and decision studies were completed using generalizability theory. Associations between settings (overall and by dimension) were calculated using Pearson's correlation.A total of 49 paramedic trainees were assessed using both a SBA and WBA. The mean score in the SBA and WBA settings were 4.88 (SD = 0.68) and 5.39 (SD = 0.48), respectively, out of a possible 7. Reliability for the SBA and WBA settings reached 0.55 and 0.49, respectively. A decision study revealed 10 and 13 cases would be needed to reach a reliability of 0.7 for the SBA and WBA settings. Pearson correlation reached 0.37 (p = 0.01) between settings, which rose to 0.73 when controlling for imperfect reliability; five of seven dimensions (situation awareness, history gathering, patient assessment, decision making, and communication) reaching significance. Two dimensions (resource utilization and procedural skills) did not reach significance.For five of the seven dimensions believed to represent the construct of paramedic clinical performance, scores obtained in the SBA were associated with scores obtained in real clinical contexts with real patients. As SBAs are often used to infer clinical competence and predict future clinical performance, this study contributes validity evidence to support these claims as long as the importance of sampling performance broadly and extensively is appreciated and implemented.

Simulation-based education requires significant time and resources. As such, educators are often required to provide evidence that the program accomplishes the desired goals, and that the performance measures obtained in this format are valid and reliable. In this light, the current chapter provided an overview of two related concepts. Program evaluation is conducted to determine whether a program led to the desired outcomes (outcomes-based evaluation) and to determine how a program was implanted (process-based evaluation). In a related goal, assessment of learning is conducted to determine a learner’s level of knowledge or ability, and requires attention to ensuring the reliability and validity of the measures used.

This study sought to better understand experiences of psychological distress and physiological stress in police communicators. One-hundred and thirteen police communicators from both rural and urban areas completed questionnaires that addressed psychological distress (acute anxiety, depression, and post-traumatic stress), coping strategies, social supports, and locus of control. Communicators reported high levels of post-traumatic stress disorder (PTSD), but had levels of anxiety and depression that were within normal limits. Levels of PTSD and depression increased with years of employment. Emotion-focused coping was the strongest predictor of PTSD, anxiety, and depression. Coping styles were not associated with physiological stress. Social support was negatively associated with depression; internal control was negatively associated with depression and anxiety, but not with PTSD or cortisol. As coping strategies are modifiable, they should be the focus of workplace interventions in order to mitigate risk ...

ObjectivesSubstantial research demonstrates that the stressors accompanying the profession of paramedicine can lead to mental health concerns. In contrast, little is known about the effects of stress on paramedics’ ability to care for patients during stressful events. In this study, we examined paramedics’ acute stress responses and performance during simulated high-stress scenarios.MethodsTwenty-two advanced care paramedics participated in simulated low-stress and high-stress clinical scenarios. The paramedics provided salivary cortisol samples and completed an anxiety questionnaire at baseline and following each scenario. Clinical performance was videotaped and scored on a checklist of specific actions and a global rating of performance. The paramedics also completed patient care documentation following each scenario.ResultsThe paramedics demonstrated greater increases in anxiety (P < .05) and salivary cortisol levels (P < .05) in response to the high-stress scenario compared to the low-stress scenario. Global rating scores were significantly lower in the high-stress scenario than in the low-stress scenario (P < .05). Checklist scores were not significantly different between the two scenarios (P = .12). There were more errors of commission (reporting information not present in the scenario) in the patient care documentation following the high-stress scenario than following the low-stress scenario (P < .05). In contrast, there were no differences in omission errors (failing to recall information present in the scenario) between the two scenarios (P = .34).ConclusionClinical performance and documentation appear vulnerable to the impact of acute stress. This highlights the importance of developing systems and training interventions aimed at supporting and preparing emergency workers who face acute stressors as part of their every day work responsibilities.LeBlanc VR, Regehr C, Tavares W, Scott AK, MacDonald R, King K. The impact of stress on paramedic performance during simulated critical events. Prehosp Disaster Med. 2012;27(4):1-6.

Introduction The assessment of children at risk of abuse and neglect is a critical societal function performed by child protection workers in situations of acute stress and conflict. Despite efforts to improve the reliability of risk assessments through standardized measures, available tools continue to rely on subjective judgment. The goal of this study was to assess the stress responses of child protection workers and their assessments of risk in high conflict situations. Methods Ninety-six child protection workers participated in 2 simulated scenarios, 1 non-confrontational and 1 confrontational. In each scenario, participants conducted a 15-minute interview with a mother played by a specially trained actor. Following the interview, the workers completed 2 risk assessment measures used in the field at the time of the study. Anxiety was measured by the State-Trait Anxiety Inventory at baseline and immediately following the completion of each interview. Physiological stress as measured by salivary cortisol was obtained at baseline as well as 20 and 30 minutes after the start of each interview. Results Participants demonstrated significant stress responses during the 1st scenario, regardless of whether the interview was confrontational or not. During the second scenario, the participants did not exhibit significant cortisol responses, however the confrontational interview elicited greater subjective anxiety than the non-confrontational scenario. In the first scenario, in which the workers demonstrated greater stress responses, risk assessment scores were higher on one risk assessment tool for the confrontational scenario than for the non-confrontational scenario. Conclusion The results suggest that stress responses in child protection workers appear to be influenced by the novelty of a situation and by a parent's demeanor during interviews. Some forms of risk assessment tools appear to be more strongly associated than other with the workers’ subjective and physiological stress responses. This merits further research to determine which aspects of risk assessment tools are susceptible to the emotional elements of intake interviews.

This study examined the association between symptoms of posttraumatic stress, coping styles, and subjective and biological responses in paramedics confronted with a simulated high-acuity event. Twenty-two advanced-care paramedics participated in a high-stress-simulated clinical scenario using a computerized human patient simulator. The Coping Inventory for Stressful Situations and the Impact of Event Scale–Revised were administered prior to participation in the scenario to ascertain preexisting coping styles and posttraumatic stress. Subjective anxiety, as measured by the State-Trait Anxiety Inventory, and acute physiological stress as measured by salivary cortisol levels, were assessed at baseline, and in response to the scenario. Results revealed that posttraumatic stress was not associated with biological or subjective indicators of stress. This suggests that high levels of posttraumatic stress among paramedics do not place them at increased risk of distress during high-stress clinical situations. Acut...

INTRODUCTION Human factors have been identified as root causes of human error in medicine. The "Anesthetists' Non-Technical Skills (ANTS) system" evaluates the effect of simulation training and debriefing on nontechnical skills (NTS). Studies suggest that residents' NTS may improve after simulation training but the effect on NTS of practicing anesthesiologists is unclear. The purpose of this study was to determine whether high-fidelity simulation training and debriefing improved the NTS of practicing anesthesiologists using the ANTS tool. METHODS In a previous study, 67 practicing anesthesiologists managed a 45-minute standardized anesthetic case using high-fidelity simulation and returned 5 to 9 months later to manage a second case. After Research Ethics Board approval, two blinded video reviewers, trained in the use of the ANTS system, evaluated archived videotapes of the 59 subjects who completed both sessions. Results were analyzed with a mixed-design analysis of variance. Interrater reliability was calculated using the intraclass correlation coefficient. RESULTS Interrater reliability for the ANTS scoring was 0.436, P < 0.05. Overall, ANTS scores improved approximately 5% from session 1 to 2 (P < 0.01), but there was no effect due to debriefing. The situational awareness ANTS category showed a statistically significant effect of debriefing (P < 0.05). CONCLUSIONS The relatively short simulation intervention, the length of time until the posttest was completed, well-developed NTS in practicing physicians, and a tool that might not be the optimal method of measurement may all account for the lack of improvement in NTS of practicing anesthesiologists as demonstrated in this study.

A large body of research using simulation in healthcare has focused on simulation itself as an object of research. However, simulation can also be used in research on human or system performance. It can be used to investigate the effects of performance shaping factors that would otherwise be difficult to study in the actual clinical setting due to practical constraints or ethical concerns. In this monograph, we illustrate various ways in which simulation has been used to study performance shaping factors. We also discuss possible directions for future research as well as methodological considerations for researchers engaging in this approach to study performance shaping factors.

Medical Education 2011: 45: 678–687 Context Little is known about health professionals’ responses to acute stressors encountered in the clinical environment. The goal of this study was to measure the subjective and physiological stress responses of medical students to consultations in familiar (in-hospital) and unfamiliar (ambulatory) settings. We hypothesised that: (i) providing a consultation in an unfamiliar setting would result in increased stress responses in medical students, and (ii) some differences in stress responses according to gender might become apparent. Methods A quantitative cross-over study was conducted over a 6-month period. Participating students were invited to provide consultations to patients in an ambulatory setting. In order to provide a control condition, each student was required to conduct a similar consultation (without reporting back to the patient) with an in-hospital patient during his or her rotation in internal medicine. Pre- and post-consultation subjective and physiological responses were measured using a visual analogue scale (VAS), the State-Trait Anxiety Inventory (STAI), a cognitive appraisal scale and salivary cortisol levels. Results All of the subjective and physiological stress responses were greater in the ambulatory setting than the in-hospital setting. There was an effect of gender on the responses. Women showed greater pre-consultation subjective stress levels in the ambulatory setting, whereas men exhibited greater physiological stress levels in the ambulatory setting. No correlations were observed between subjective and cortisol responses. Conclusions Ambulatory consultations are more stressful for medical students than consultations carried out in the more familiar in-hospital setting. Further studies should be conducted to investigate the nature of the stressors in this particular environment, to explore the possible explanations for a gender effect, and to explore the effects of these stress responses on students’ diagnostic skills.

A growing number of faculty are engaging in research in health professions education. Suggestions continue to be made in the literature for a clear and less onerous pathway for the ethical review of this work.We aim to provide advice about the ethics application process for those conducting research in health professions education.We used critical reflection of our experiences as research ethics board (REB) members, applying for, reviewing and consulting about the ethics application process in both UK and Canadian health contexts in addition to evidence and advice that is available in the literature to inform the tips provided.Twelve tips are offered to help faculty understand and navigate through the ethics application process.Health professionals have an important role to play in advancing the field of health professions education, and despite issues identified with current review pathways, REB review is in place to ensure that this work is undertaken safely and ethically. We believe the tips offered in this article will help faculty identify, and devise plans to address, some ethical issues that are common in health professions education research.

Research has identified high levels of trauma exposure and PTSD in professionals responsible for assessing children at risk for abuse. An important question arising is the influence of stress and trauma on professional judgment. This study examined the association between critical incident exposure, PTSD and workers' judgments of child risk. Ninety-six child protection workers participated in 2 simulated clinical interviews and subsequently completed standardized risk assessment measures. Workers reported high levels of exposure to critical events in the workplace and high levels of traumatic stress symptoms. Number of prior critical events encountered was negatively associated with assessment of risk. Level of traumatic stress symptoms was negatively associated with risk on one, but not other measures of risk. It is concluded that standardized measures for assessing a child's risk of abuse may be influenced by previous exposure to critical workplace events and levels of traumatic stress in workers.

Objective: Child welfare agencies have moved toward standardized risk assessment measures to improve the reliability with which child’s risk of abuse is predicted. Nevertheless, these tools require a degree of subjective judgment. Research to date has not substantially investigated the influence of specific context and worker characteristics on professional judgment in the use of risk assessment measures. Method: This research utilized standardized patients performing in scenarios to depict typical child welfare cases. Ninety-six workers interviewed two ‘‘families,’’ completed risk assessment measures, and then participated in interviews regarding their subjective views of their decision making and performance. Results: There was considerable variability in risk appraisals. Confidence in risk assessment performance was related to age, acute level of stress, and the worker’s perceived ability to engage family members. Confidence in risk assessment was further related to case variables. Confidence was not related to level of risk assessed. Conclusion: The variation in risk assessment appraisals in this study, despite at times high rates of worker confidence in their appraisals, speaks to the need for ongoing consultation and increased decision support strategies even among highly skilled and trained workers.

OBJECTIVES Training and practice in medicine are inherently stressful. Research into the effects of acute stressors has revealed significant variability in individual responses to stressors, with performance impairments occurring in those who demonstrate elevated subjective and physiological responses. Cognitive appraisals (subjective assessment of situational demands and available resources) of a stressor have been proposed as a predictor variable in stress responses. However, the relationship between cognitive appraisal and stress responses has not been tested empirically in complex realistic situations. The purpose of this study was to determine the extent to which cognitive appraisal affects a medical trainee's subjective and physiological stress responses to high-acuity simulated clinical situations. METHODS Thirteen emergency medicine and general surgery residents participated in high (HS) and low (LS) stress trauma resuscitation simulations. Subjective (cognitive appraisal and State-Trait Anxiety Inventory [STAI]) and physiological (salivary cortisol) measures were collected at baseline and in response to participation in each scenario. RESULTS Post-scenario STAI scores, cognitive appraisal and cortisol levels were higher in the HS scenario compared with the LS scenario. For the participants who appraised the scenarios as 'threats' (in which the demands outweighed the resources), the ratio of perceived demands to resources was positively correlated with cortisol levels (r = 0.59, p < 0.05) and STAI responses (r = 0.64, p < 0.05). By contrast, for the participants who appraised the scenarios as 'challenges' (in which resources were sufficient to meet the demands), the perceived ratio of demands to resources was not correlated with either the STAI scores or cortisol levels. CONCLUSIONS Subjective appraisals of a situation appear to play an important role in stress responses, which have previously been shown to impair performance. As such, training for high-acuity events should include interventions targeting stress management skills.

Hazardous materials gloves (HAZMAT) are frequently worn when performing clinical technical skills, but it is unclear how sensory and motor performance is affected in these circumstances. In Experiment 1, two timed standardized manual dexterity tests, and a test of sensory function were administered. Glove use resulted in a decreased ability to ma- nipulate small objects and a decreased sensitivity to light touch. However, the ability to manipulate objects with a tool was unaffected by the glove. In Experiment 2, the objects were instrumented with a force/torque sensor and the coefficient of friction between the digits and the object was estimated. An elevation of grasping forces and an increased slipperiness be- tween the digits and the object were observed. In Experiment 3, fingertip placement was quantified with pressure sensitive sheets and revealed a misalignment of the digits. Collectively these results suggest that impairments to motor performance when wearing a glove might be related to misalignment of the digits, associated with sensory decrement. These results can be used in the formulation of protocols for professionals wearing HAZMAT gloves and in the design of tools and HAZ- MAT garments.

BACKGROUND: Intensive care units (ICUs) are recognized as stressful environments. However, the conditions in which stressors may affect health professionals' performance and well-being and the conditions that potentially lead to impaired performance and staff psychological distress are not well understood. OBJECTIVES: The purpose of this study was to determine healthcare professionals' perceptions regarding the factors that lead to stress responses and performance impairments during ICU medical crises. DESIGN: A qualitative study in a university-affiliated ICU in Canada. METHODOLOGY: We conducted 32 individual semistructured interviews of ICU nurses, staff physicians, residents, and respiratory therapists in a university-affiliated hospital. The transcripts of the audiotaped interviews were analyzed using an inductive thematic methodology. RESULTS: Increased workload, high stakes, and heavy weight of responsibility were recognized as common stressors during ICU crises. However, a high level of individual and team resources available to face such demands was also reported. When the patient's condition was changing or deteriorating unpredictably or when the expected resources were unavailable, crises were assessed by some team members as threatening, leading to individual distress. Once manifested, this emotional distress was strongly contagious to other team members. The ensuing collective anxiety was perceived as disruptive for teamwork and deleterious for individual and collective performance. CONCLUSIONS: Individual distress reactions to ICU crises occurred in the presence of unexpectedly high demands unmatched by appropriate resources and were contagious among other team members. Given the high uncertainty surrounding many ICU medical crises, strategies aimed at preventing distress contagion among ICU health professionals may improve team performance and individual well-being.

The Integrated Procedural Performance Instrument (IPPI) consists of clinical scenarios in which bench-top models are positioned to simulated patients. Trainees are required to perform technical skills while engaging with the patient. The purpose of this study was to determine whether an IPPI format examination could discriminate between different levels of trainees.Sixteen fourth-year medical students and 16 first-year surgery residents participated in 4 IPPI scenarios. Videotaped performances were scored by 2 blinded independent clinician raters on previously validated instruments: checklist of technical skills, Global Rating Scale of technical skills, and communication scale. We conducted separate mixed design analyses of variance (level x cases) on the 3 scales.Residents performed better than medical students on the checklist (74% vs 60%, P.05), the Global Rating Scale of technical skills (75% vs 56%, P.01), and the coherence communication subscale (79% vs 69%, P.05).An IPPI examination discriminated between students' and residents' technical skills and coherence in communication skills. It also highlighted a potential gap in the training of residents' communication skills.

Emergency personnel consistently work under high-stress situations, and thus, the question about whether this stress affects performance is critical to the safety of both themselves and the public. However, considerable controversy exists about the influence of stress on performance. This study investigates the association between both biological and psychological manifestations of stress and performance. The study was conducted with 84 police recruits using a high-fidelity simulation of a policing event in order to try to determine performance in a life-like workplace environment. Measures included both biological (heart rate and salivary cortisol levels) and psychological (subjective anxiety) indicators of stress. Performance was videotaped and was later evaluated by three expert raters. The results of this study are promising in that neither physiological nor psychological responses impaired performance in a simulated acutely stressful policing situation. On the other hand, those individuals with greater cortisol release showed higher levels of performance, supporting the notion that cortisol can enhance ability in high-stress situations. Recruits were also asked to subjectively evaluate their performance. A small group of individuals ranked themselves as poor performers while evaluators ranked them highly. These individuals experienced significantly higher increase in subjective distress and significantly higher cortisol levels at baseline and peak. Copyright © 2008 John Wiley & Sons, Ltd.

This study investigated the relationship between coping styles and police recruits' stress responses and performance during a stressful event and the relationship between coping styles and traumatic symptoms. Recruits participated in a simulated stressful policing situation and were scored by expert

OBJECTIVE Previous research has revealed a pedagogical benefit of instructing novice diagnosticians to utilise a combined approach to clinical reasoning (familiarity-driven pattern recognition combined with a careful consideration of the presenting features) when diagnosing electrocardiograms (ECGs). This paper reports 2 studies demonstrating that the combined instructions are especially valuable in helping students overcome biasing influences. METHODS Undergraduate psychology students were trained to diagnose 10 cardiac conditions via ECG presentation. Half of all participants were instructed to reason in a combined manner and half were given no explicit instruction regarding the diagnostic task. In Study 1 (n = 60), half of each group was biased towards an incorrect diagnosis through presentation of counter-indicative features. In Study 2 (n = 48), a third of the test ECGs were presented with a correct diagnostic suggestion, a third with an incorrect suggestion, and a third without a suggestion. RESULTS Overall, the instruction to utilise a combined reasoning approach resulted in greater diagnostic accuracy relative to leaving students to their own intuitions regarding how best to approach new cases. The effect was particularly pronounced when cases were made challenging by biasing participants towards an incorrect diagnosis, either through mention of a specific feature or by making an inaccurate diagnostic suggestion. DISCUSSION These studies advance a growing body of evidence suggesting that various diagnostic strategies identified in the literature on clinical reasoning are not mutually exclusive and that trainees can benefit from explicit guidance regarding the value of both analytic and non-analytic reasoning tendencies.

Objective: The immediate and long-term effects of traumatic exposure and subsequent posttraumatic stress reactions in people in high-risk occupations are well-documented. What is less evident is the impact of this traumatic exposure and subsequent traumatic stress symptoms on workers' response to acute stress situations. This study aimed to examine the association between prior traumatic exposure related to policing, current posttraumatic stress symptoms and biological markers of stress, and subjective appraisal of stress before, during, and after exposure to acutely stressful stimuli. Method: A stressful policing situation was created through the use of a video simulator room. Participants' responses to the simulated emergency were evaluated by monitoring heart rate, collecting salivatory samples for cortisol analysis, and repeated administration of a subjective measure of anxiety. Results: Biological indicators of stress, as measured by cortisol level and heart rate, were not associated with previous trauma exposure or trauma symptoms; however, biological response was associated with subjective anxiety. Vulnerability to psychological stress responses during an acute stress situation was also associated with lower levels of social support, previous traumatic exposures, and preexisting symptoms of traumatic stress. The importance of these factors became more pronounced as time progressed after the event. Conclusion: Previous trauma exposure did not put individuals at increased risk of biological distress during an acute stress situation. However, previous trauma and reduced social supports were associated with continuing psychological distress, confirming previous research and raising concerns about the cumulative negative effects of traumatic exposure on psychological health in emergency responders.

CONTEXT Despite the finding that residents are exposed to significant stressors during their training, little is known about the impact of these stressors on performance. The objectives of this project were to measure the subjective anxiety felt by emergency medicine (EM) residents during in-training examinations, and to determine the effect of this anxiety on their ability to diagnose visual stimuli such as X-rays, photographs and electrocardiographs. METHODS Two examinations, matched for difficulty and length, were constructed based on the performance of 23 residents in 2 Royal College of Physicians and Surgeons of Canada (RCPSC) EM residency programmes. These examinations were then administered at 2-week intervals to another 24 residents in 2 additional RCPSC EM programmes. One examination was administered under high-stress conditions (in-training examination) and the other under low-stress (control) conditions. Perceived anxiety was measured using the state scale of the State-Trait Anxiety Inventory before and after each iteration of the examination. RESULTS Residents reported higher levels of anxiety in the high-stress condition (41.5 versus 35.9, P < 0.05). Examination scores were higher in the high-stress condition (70.4 versus 64.4, P < 0.01). The scores of junior residents improved in the high-stress condition, whereas those of intermediate and senior residents did not change. CONCLUSIONS Emergency medicine residents report higher anxiety during in-training examinations compared with control conditions. Residents at all levels exhibited similar perceptions of anxiety. Junior residents performed better under stress, achieving higher scores during the in-training examination than during the control condition. The performance of more experienced residents was not affected by the stress condition.

We carried out a prospective, randomized, 4-arm study including control arm, blinding of examiners to determine effectiveness of computer-based video instruction (CBVI) and different types of expert feedback (concurrent and summary) on learning of a basic technical skill.Using bench models, participants were pre-tested on a suturing and instrument knot-tying skill after viewing an instructional video. The students were subsequently assigned randomly to 4 practice conditions: no additional intervention (control), self study with CBVI, expert feedback during practice trials (concurrent feedback), and expert feedback after practice trials (summary feedback). All participants underwent 19 trials of practice, over 1 hour, in their assigned training condition. The effectiveness of training was assessed both at an immediate post-test and 1 month later at a retention test. Performance was evaluated using both expert-based (Global Rating Scores) and computer-based assessment (Hand Motion Analysis). Data were analyzed using repeated-measures ANOVA.There were no differences in GRS between groups at pre-test. The CBVI, concurrent feedback and summary feedback methods were equally effective initially for the instruction of this basic technical skill to naive medical students and displayed better performance than control (control, 12.71 [10.79 to 14.62]; CBVI, 16.39 [14.38 to 18.40]; concurrent, 16.97 [15.79 to 18.15]; summary, 16.09 [13.57 to 18.62]; P.001 each). At retention. however, only CBVI and summary feedback groups retained superior suturing and knot-tying performance versus control (control, 8.13 [6.94 to 9.85]; CBVI, 11.92 [10.19 to 14.99] P = .037; concurrent, 9.80 [8.55 to 13.45] P = .635; summary, 111.19 [10.27 to 14.29] P = .037). Hand motion data displayed a similar pattern of results. There were no group differences in the rate of learning (P.05).Our study showed that CBVI can be as effective as summary expert feedback in the instruction of basic technical skills to medical students. Thoughtfully incorporated into technical curricula, CBVI can make efficient use of faculty time and serve as a useful pedagogic adjunct for basic skills training. Additionally, our study provides evidence supporting an increased role of summary feedback to effectively train novices in technical skills.

Background Computer-based video training (CBVT) provides flexible opportunities for surgical trainees to learn fundamental technical skills, but may be ineffective in self-directed practice settings because of poor trainee self-assessment. This study examined whether CBVT is effective in a self-directed learning environment among novice trainees. Methods Thirty novice trainees used CBVT to learn the 1-handed square knot while self-assessing their proficiency every 3 minutes. On reaching self-assessed skill proficiency, trainees were randomized to either cease practice or to complete additional practice. Performance was evaluated with computer and expert-based measures during practice and on pretests, posttests, and 1-week retention tests. Results Analyses revealed performance improvements for both groups (all P P > .05) on all tests. Conclusions CBVT for the 1-handed square knot is effective in a self-directed learning environment among novices. This lends support to the implementation of self-directed digital media–based learning within surgical curricula.

Enhanced podcasts increase learning, but evidence is lacking on how they should be designed to optimize their effectiveness. This study assessed the impact two learning instructional design methods (mental practice and modeling), either on their own or in combination, for teaching complex cognitive medical content when incorporated into enhanced podcasts. Sixty-three medical students were randomised to one of four versions of an airway management enhanced podcast: (1) control: narrated presentation; (2) modeling: narration with video demonstration of skills; (3) mental practice: narrated presentation with guided mental practice; (4) combined: modeling and mental practice. One week later, students managed a manikin-based simulated airway crisis. Knowledge acquisition was assessed by baseline and retention multiple-choice quizzes. Two blinded raters assessed all videos obtained from simulated crises to measure the students’ skills using a key-elements scale, critical error checklist, and the Ottawa global rating scale (GRS). Baseline knowledge was not different between all four groups (p = 0.65). One week later, knowledge retention was significantly higher for (1) both the mental practice and modeling group than the control group (p = 0.01; p = 0.01, respectively) and (2) the combined mental practice and modeling group compared to all other groups (all ps = 0.01). Regarding skills acquisition, the control group significantly under-performed in comparison to all other groups on the key-events scale (all ps ≤ 0.05), the critical error checklist (all ps ≤ 0.05), and the Ottawa GRS (all ps ≤ 0.05). The combination of mental practice and modeling led to greater improvement on the key events checklist (p = 0.01) compared to either strategy alone. However, the combination of the two strategies did not result in any further learning gains on the two other measures of clinical performance (all ps > 0.05). The effectiveness of enhanced podcasts for knowledge retention and clinical skill acquisition is increased with either mental practice or modeling. The combination of mental practice and modeling had synergistic effects on knowledge retention, but conveyed less clear advantages in its application through clinical skills.

Contains fulltext : 152730.pdf (Publisher’s version ) (Open Access) OBJECTIVE: To investigate the effect of in situ simulation (ISS) versus off-site simulation (OSS) on knowledge, patient safety attitude, stress, motivation, perceptions of simulation, team performance and organisational impact. DESIGN: Investigator-initiated single-centre randomised superiority educational trial. SETTING: Obstetrics and anaesthesiology departments, Rigshospitalet, University of Copenhagen, Denmark. PARTICIPANTS: 100 participants in teams of 10, comprising midwives, specialised midwives, auxiliary nurses, nurse anaesthetists, operating theatre nurses, and consultant doctors and trainees in obstetrics and anaesthesiology. INTERVENTIONS: Two multiprofessional simulations (clinical management of an emergency caesarean section and a postpartum haemorrhage scenario) were conducted in teams of 10 in the ISS versus the OSS setting. PRIMARY OUTCOME: Knowledge assessed by a multiple choice question test. EXPLORATORY OUTCOMES: Individual outcomes: scores on the Safety Attitudes Questionnaire, stress measurements (State-Trait Anxiety Inventory, cognitive appraisal and salivary cortisol), Intrinsic Motivation Inventory and perceptions of simulations. Team outcome: video assessment of team performance. Organisational impact: suggestions for organisational changes. RESULTS: The trial was conducted from April to June 2013. No differences between the two groups were found for the multiple choice question test, patient safety attitude, stress measurements, motivation or the evaluation of the simulations. The participants in the ISS group scored the authenticity of the simulation significantly higher than did the participants in the OSS group. Expert video assessment of team performance showed no differences between the ISS versus the OSS group. The ISS group provided more ideas and suggestions for changes at the organisational level. CONCLUSIONS: In this randomised trial, no significant differences were found regarding knowledge, patient safety attitude, motivation or stress measurements when comparing ISS versus OSS. Although participant perception of the authenticity of ISS versus OSS differed significantly, there were no differences in other outcomes between the groups except that the ISS group generated more suggestions for organisational changes. TRIAL REGISTRATION NUMBER: NCT01792674.

Both enhancements and impairments of clinical performance due to acute stress have been reported, often as a function of the intensity of an individual's response. According to the broader stress literature, peripheral or extrinsic stressors (ES) and task-contingent or intrinsic stressors (IS) can be distinguished within a stressful situation. The objective of this study was to assess the impact of IS and ES on clinical performance.A prospective randomized crossover study was undertaken with third-year medical students conducting two medical experiences with simulated patients. The effects of severity of the disease (IS) and the patient's aggressiveness (ES) were studied. A total of 109 students were assigned to four groups according to the presence of ES and IS. Subjective stress and anxiety responses were assessed before and after each experience. The students' clinical skills, diagnostic accuracy and argumentation were assessed as clinical performance measures. Sex and student-perceived cognitive difficulty of the task were considered as adjustment variables.Both types of stressors improved clinical performance. IS improved diagnostic accuracy (regression parameter β = 9.7, p = 0.004) and differential argumentation (β = 5.9, p = 0.02), whereas ES improved clinical examination (β = 12.3, p0.001) and communication skills (β = 15.4, p0.001). The student-perceived cognitive difficulty of the task was a strong deleterious factor on both stress and performance.In simulated consultation, extrinsic and intrinsic stressors both have a positive but different effect on clinical performance.

Determine whether wearing a chemical protective suit increases time to successful completion of four resuscitation skills.This prospective experimental study examined the ability of civilian paramedic personnel to complete four resuscitative skills (electrical defibrillation, administration of epinephrine subcutaneously, intravenous cannulation, and tracheal intubation) carried out using standard methods on mannequins under two test conditions (wearing the protective suit and not wearing the suit). Primary outcome was time to successful completion of each skill.Sixteen paramedics were enrolled and completed each skill under two test conditions. Paramedics took longer to complete administration of epinephrine (87 vs. 60 seconds; p0.01) and intravenous cannulation (220 vs. 158 seconds; p0.01) tasks when wearing a protective suit. Wearing the suit did not impair electrical defibrillation (57 vs. 46 seconds) or tracheal intubation (79 vs 69 seconds).Chemical protective suit use increased time to successful completion of resuscitation skills where fine motor skills are required, namely administration of epinephrine subcutaneously and intravenous cannulation, but did not increase time to successful completion of resuscitation skills requiring gross motor skills, namely electrical defibrillation and tracheal intubation.

• Il existe un vaste champ de connaissances en psychologie cognitive appliquee a l’education medicale. • Ces connaissances ont permis de mieux comprendre les processus du raisonnement, l’organisation des connaissances et le recueil de l’information clinique et de developper certaines strategies pedagogiques fondees sur des donnees probantes. • Les medecins font appel a des processus mixtes de raisonnement, associant des strategies analytiques, comme le raisonnement hypothetico-deductif, et des strategies non analytiques telle la reconnaissance spontanee d’une conjonction de signes cliniques. • L’organisation des connaissances peut prendre diverses formes dont les plus elaborees consistent en des reseaux richement interconnectes. • L’activation des connaissances passe par le plus souvent une etape de representation mentale de la teneur du probleme clinique. • L’acquisition des donnees cliniques est conditionnee par la generation precoce d’hypotheses diagnostiques. • L’apprentissage des seuls processus de raisonnement n’est pas efficace s’il ne s’accompagne pas de l’acquisition simultanee des connaissances specifiques necessaires pour resoudre un probleme clinique.