Simulation, stress, and learning

By: Victoria Brazil (@SocraticEM)


Many of our participants in simulation activities tell us they are stressed by the experience. Is that good or bad for their learning? Is that indicative of their stress in real world situations, i.e., can we understand more about stress in healthcare professionals by using simulation as a research test bed? And, finally, should we be trying to manipulate participant emotions in simulation to optimise learning and or build resilience to stress in the real world.

We’ve hosted the marvelous Vicki LeBlanc at Gold Coast Health over the last month, and her visit has prompted reflection on how stress and simulation are intertwined. Professor LeBlanc leads research on the effects of emotions (particularly stress) on the learning and performance of health professionals and trainees. Her paper with Glenn PosnerEmotions in simulation-based education: friends or foes of learning? –  is a wonderful deep dive into this topic

Another recent publication – A scoping review of emotions and related constructs in simulation-based education research articles – highlights how poorly understood stress and emotions are in simulation, and the heterogeneity of research in this area. Conceptualizations of ‘stress’, ‘emotion’ and ‘emotional intelligence’ vary, as do measurement tools, and research methodologies.

Using these two resources let’s consider each of those initial questions.

Q. Is stress in sim good or bad for learning?

A. It depends.

Emotional activation does impact memory, but not always in predictable ways, and not always to increase retention of the things we want learners to remember. In particular, high stress may simply add to extraneous load and reduce learning and schema formation. When learning is occurring in groups, the impact of emotions on learning will likely vary widely between members of the group. So – sadly – there is no ideal or easy to identify ‘sweet spot’ for optimal learning in simulation.

The best we might do is to attune to when emotions are detrimental to learning and mitigate these effects. We’re fortunate to have a host of guidance on this topic, often intertwined with literature about psychological safety.

 Q. Can we use sim to research stress responses and health professionals’ ability to recognise and regulate their emotions to preserve performance?

A. Yes!

Many questions can be explored in this way, using various self-report instruments and/or biometric data (eg. HR, HRV, fNIRS and galvanic skin response to measure cognitive load.) For example, LeBlanc found paramedics undertaking high stress versions of scenarios were more likely to make errors in calculation of drug doses.

Q. Can we (and should we) try and manipulate emotions in simulation-based education to enhance learning effect or ‘inoculate’ health professionals against stress.

A. With great caution!

We’ve considered this topic before on the blog and in a subsequent publication. Authentic, ‘everyday’ scenarios will likely be quite rich with issues relating to stress and emotional activation, without needing to introduce distracting additional stressors. And yet this manipulation appears to be quite common, with the scoping review previously cited suggesting that “the typical SBE scenario in our review featured stress-inducing, negative emotion eliciting experiences” Maybe its time to revisit our typical scenarios…

And, finally …..

Looking to extend your own knowledge in this area to use as a sim facilitator ( and may be send as pre-reading to your participants) Look no further than this wonderful review of how to coach health professionals in recognizing and regulating emotion can be found here.

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