Age and its impact on crisis management performance and learning after simulation-based education by acute care physicians: a multicentre prospective cohort study.

BACKGROUND: Physiological changes associated with ageing could negatively impact the crisis resource management skills of acute care physicians. This study was designed to determine whether physician age impacts crisis resource management skills, and crisis resource management skills learning and retention using full-body manikin simulation training in acute care physicians. METHODS: Acute care physicians at two Canadian universities participated in three 8-min simulated crisis (pulseless electrical activity) scenarios. An initial crisis scenario (pre-test) was followed by debriefing with a trained facilitator and a second crisis scenario (immediate post-test). Participants returned for a third crisis scenario 3-6 months later (retention post-test). RESULTS: For the 48 participants included in the final analysis, age negatively correlated with baseline Global Rating Scale (GRS; r=-0.30, P<0.05) and technical checklist scores (r=-0.44, P<0.01). However, only years in practice and prior simulation experience, but not age, were significant in a subsequent stepwise regression analysis. Learning from simulation-based education was shown with a mean difference in scores from pre-test to immediate post-test of 2.28 for GRS score (P<0.001) and 1.69 for technical checklist correct score (P<0.001); learning was retained for 3-6 months. Only prior simulation experience was significantly correlated with a decreased change in learning (r=-0.30, P<0.05). CONCLUSIONS: A reduced amount of prior simulation training and increased years in practice, but not age on its own, were significant predictors of low baseline crisis resource management performance. Simulation-based education leads to crisis resource management learning that is well retained for 3-6 months, regardless of age or years in practice.

Impact of Unexpected Death in a Simulation Scenario on Skill Retention, Stress, and Emotions: A Simulation-Based Randomized Controlled Trial.

Introduction The simulation of patient death remains controversial in simulation-based education. We investigated the effect of simulated patient death on learners' skill retention, stress levels, and emotions. Methods After ethics approval, we recruited residents at two Canadian universities. Participants were randomized to manage a simulated cardiac arrest ending with either the unexpected death (intervention group) or survival (control group) of the simulated patient (i.e., manikin). Three months later, all participants performed the same scenario but with the opposite outcome. Blinded video raters assessed participants' non-technical and technical crisis resource management (CRM) skills at both time points. Stress levels (represented by anxiety level, salivary cortisol concentration, and cognitive appraisal) and emotional valence were measured. Outcomes were analyzed using analysis of covariance (ANCOVA) or generalized estimating equations as appropriate. Results The analysis included 46 participants (intervention: n=24; control: n=22). Simulated death neither affected retention of non-technical CRM skills (mean retention Ottawa Global Rating Scale score in the death group [29.4, 95% CI: 27.0, 31.8] versus control group [29.4, 95% CI: 26.8, 32.0; p=0.87]) nor technical CRM skills (mean retention task-specific checklist score in the manikin death group [11.8, 95% CI: 10.5, 13.0] versus the control group [12.5, 95% CI: 11.3, 13.7; p=0.69]). The simulated death had negative effects on participants' anxiety levels, cognitive appraisal, and emotions. Conclusion Simulated patient death did not affect the retention of non-technical or technical CRM skills but led to greater levels of short-term anxiety, stress, and negative emotions among learners.

The impact of Stress Management and Resailience Training (SMART) on academic physicians during the implementation of a new Health Information System: An exploratory randomized controlled trial.

OBJECTIVE: The Stress Management and Resilience Training (SMART) program is an evidence-based intervention designed to build resilience in physicians in clinical practice. The objective of the current study was to assess the impact of the SMART program on academic physicians' levels of resilience, subjective happiness, stress, and anxiety, and specifically during the implementation of a new hospital-wide Health Information System (HIS). METHODS: A total of 40 physicians in a tertiary care academic hospital were randomized (allocation ratio 1:1) to either the SMART intervention or the control condition. The SMART intervention consisted of one mandatory two-hour in-person workshop and an optional 24-week online program, designed to support the materials delivered in the workshop. Outcome measures were assessed using validated scales administered online at baseline and at 3-months and 6-months follow-up. RESULTS: After adjusting for baseline levels of each outcome, no statistically significant intervention effect was observed for resilience, subjective happiness, stress or anxiety at 3-months or 6-months follow-up. However, physicians in the intervention group demonstrated improvements in resilience, stress and anxiety at follow-up that were within the range of clinically relevant differences. CONCLUSIONS: The findings of this exploratory study provide modest support that the SMART intervention may be beneficial for proactively addressing physician wellness during the implementation of a new HIS and that larger randomized trials are warranted. TRIAL REGISTRATION: NCT04384861.

Emotions in simulation-based education: friends or foes of learning?

In simulation-based education, there is growing interest in the effects of emotions on learning from simulation sessions. The perception that emotions have an important impact on performance and learning is supported by the literature. Emotions are pervasive: at any given moment, individuals are in one emotional state or another. Emotions are also powerful: they guide ongoing cognitive processes in order to direct attention, memory and judgment towards addressing the stimulus that triggers the emotion. This occurs in a predictable way. The purpose of this paper is to present a narrative overview of the research on emotions, cognitive processes and learning, in order to inform the simulation community of the potential role of emotions during simulation-based education.

Wrestling With the Invincibility Myth: Exploring Physicians' Resistance to Wellness and Resilience-Building Interventions.

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.

Perceived organizational support and emotional labour among police communicators: what can organizational context tell us about posttraumatic stress?

OBJECTIVE: As central members of the emergency response system, communicators are regularly exposed to potentially traumatic events and experience some of the highest rates of posttraumatic stress. Given elevated rates of distress, they are regularly called upon to manage emotions-their own and others'-during high-risk and high-stress situations, within a highly controlled organizational context. Emotional labour (EL) theory suggests that many individuals faced with this challenge utilize a strategy in which emotions are suppressed or faked (surface acting-SA) in keeping with organizational expectations. METHODS: This study was designed to examine the relationships among reported EL, perceived organizational support, job stress, and severity of posttraumatic stress among a population of communicators. RESULTS: Job pressure and perceived lack of organizational support were positively associated with posttraumatic stress. Although the highest reported levels of SA occurred when interacting with members of the public, this SA was not associated with posttraumatic stress, unlike SA with co-workers and supervisors. SA with co-workers and supervisors was further related to perceptions of lack of organizational support. CONCLUSION: Thus, an organization perceived as unsupportive may create a culture in which individuals are dissuaded from expressing true emotions with colleagues and supervisors, potentially magnifying the traumatic effects of exposure to critical incidents.

A cross-sectional study of the interrelationship between burnout, empathy and resilience in academic physicians.

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.

Ontario Dentists' Practice of Sedation and General Anesthesia: Barriers to Access and Use.

BACKGROUND: To investigate, among Ontario dentists, (1) self-reported barriers to access to sedation and general anesthesia (GA) services and (2) their current use of sedation and GA. METHODS: Of Ontario dentists practising, 3001 were randomly selected to complete a 16-question survey by mail or online in 2011. Mixed analysis of variance (ANOVA) followed by independent-sample t tests or 1-way ANOVA evaluated the relation between dentists' views and demographic variables including sex, clinical experience and size of primary practice. RESULTS: Of the participants (n = 1076; 37.9% response rate), 69.7% were male, 84.4% were general practitioners, mean time in practice was 20.6 years (0.5-42 years) and 42.2% were in cities of over 500 000 people. Most dentists (60.2%) provided anesthesia services, although 38.2% indicated lack of training and the belief that there is no patient demand (25.3%) as reasons not to use anesthesia in their offices. Nitrous oxide was used 17.5% of the time for all dental procedures except implants. Barriers to referral of patients for anesthesia services included high costs associated with sedation/GA (72.2%) and patient fear of anesthesia (33.5%). CONCLUSION: This study identified a perceived lack of patient demand, lack of dentist training, high costs of sedation/GA and patient fear of sedation/GA as primary barriers to use of sedation/GA in Ontario dental practices. The use of various anesthesia modalities is diverse, with 60.2% of dentists providing sedation/GA.

Does prior exposure to clinical critical events influence stress reactions to simulation session in nursing students: A case-control study.

BACKGROUND: Simulation is a pedagogical method known to be a generator of stress, that could be influenced by previous stressful experiences. OBJECTIVES: 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. DESIGN: Observational case-control study. SETTINGS: Four critical event scenarios were created using full-scale simulation. PARTICIPANTS: 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. METHODS: Stress levels were assessed using the self-report stress numerical rating scale-11. RESULTS: 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). CONCLUSIONS: 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.

The "Managed" or Damaged Heart? Emotional Labor, Gender, and Posttraumatic Stressors Predict Workplace Event-Related Acute Changes in Cortisol, Oxytocin, and Heart Rate Variability.

Vital to the everyday operation of police services, police communicators (911 call-takers and dispatchers) are persistently subject to imminent challenges in the workplace; they must always be prepared to engage and deal with a wide variety of circumstances that provoke various intense emotions and physiological stress responses. Acute changes in cortisol, oxytocin, and heart rate variability are central to adaptive responses in stressful complex social interactions, but they might also be indicative of physiological dysregulation due to long-term psychosocial stress exposures. Thus, we examine acute stress-induced release of peripheral oxytocin and cortisol along with changes in heart rate variability, and how each relates to persistent workplace stressors and symptoms of posttraumatic stress. Findings indicate chronic forms of gendered workplace stress such as emotional labor, gender role stress and, posttraumatic stress each have differential associations with, and predict physiological responses to, acutely stressful events in the workplace. These associations suggest potential mechanisms through which communicators become more vulnerable to developing stress-related disorders such as posttraumatic stress injuries, especially after cumulative traumatic exposures in this context. The results also suggest potential pathways for the biological embedding of stressful gendered workplace experiences.