Stress Exposure Simulations – Training or Terrifying?

By Victoria Brazil (@SocraticEM)

Image: An emergency department team plots their perceived stress level and performance on the Yerkes Dodson curve immediately after a ‘stress exposure’ simulation.

Healthcare workers often have to perform under stressful conditions. This is most obvious in time critical or lifesaving patient encounters, but equally challenging are difficult conversations with patients or colleagues, or whenever demand overwhelms resources in our complex environments. ‘Task specific’ training helps – doing our jobs more effectively and efficiently raises the threshold for when we ‘get stressed’. But perhaps there is also merit in learning to recognise and regulate the stress itself?  

Lessons from other high-risk industries suggest this is a good idea. Research with acute care providers supports specific stress management training.  

I believe ‘Stress exposure’ or ‘stress inoculation’ simulation might help achieve this aim, but caution against careless application of the technique.

Too often I have seen (and been guilty of delivering) simulations that were stressful because they were badly designed, participants were poorly prepared, and/or debriefings lacked psychological safety. ‘Inoculation’ against this kind of stress mostly looks like learners not wanting to attend simulations ever again, but facilitators often believe the learners are ‘toughened up’ in this way.

So how should stress exposure simulations be designed, delivered and debriefed?

We don’t know for sure. Our group at Gold Coast Health is undertaking a study on the topic, in a partnership between our simulation group and the Bond University Tactical Research Unit. Most descriptions of stress inoculation simulation training are drawn from critical care contexts, as are explicit guidance for psychological skills for healthcare professionals.

Based on our literature review, our first 6-month experience with emergency department teams, and our background in simulation training, we suggest: –

  • Reading about the experience and approach of others within healthcare and in other contexts.
  • Integrate stress exposure simulations into an established simulation program where trust and psychological safety are more established within the learner group
  • Send written pre-reading for participants. Clarify that the primary aim of the session is to enhance recognition of self and team stress, its impact on performance, and individual and team strategies to mitigate this. Include some ‘content’ pre-reading on psychological skills.
  • Introduce the session with careful and unhurried pre-briefing. Re-iterate the purpose of the simulation and provides an opportunity for sharing experience on 3 topics – “what are the sources of stress at work, what are the impacts, and what do you find helps?”. Integrate some didactics into the conversation. We draw the Yerkes Dodson curve on a white board as a simple (albeit imperfect) visual representation. Explain that the simulation will be overwhelming and clarify any deviations from usual ground rules for simulation (e.g. deception, equipment not working, etc)
  • Design and deliver scenarios that have a realistic clinical focus for the participant group – but with elements that add cognitive load e.g. time compression, distraction and interruption.
  • Consider using physiologic data e.g. heart rate or heart rate variability (HRV) monitoring. This is an imperfect measure of psychological stress, but may serve as a reflection tool 
  • Debrief using the same 3 layered framework – sources of stress, impacts, and personal or team strategies to mitigate. We ask participants to plot their point of maximal stress on the Yerkes Dodson curve after they return from the simulation space. Attend to psychological safety in well-established ways, including normalising and validating experience.
  • Encourage practical transfer of skills and strategies to the clinical environment, but also attune to the possibility of more extreme distress in the session and follow up with participants.

Our practice remains a ‘work in progress’ so would welcome others experience or thoughts.


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