Adding emotional stressors to training in simulated cardiopulmonary arrest enhances participant performance

Advanced cardiac life support (ACLS) skills tend to degrade over time. There is mounting evidence that high-fidelity simulation (HFS) is advantageous to teaching ACLS. The aspects of HFS that enhance learning are not entirely clear, but the anxiety generated by a scenario may enhance retention through well-established learning pathways. We sought to determine whether an HFS with added emotional stress could provoke anxiety and, if so, whether or not participants learning ACLS would demonstrate better written and applied knowledge retention 6 months after their initial course.

Twenty-five student volunteers from Year 1 and 2 at Mount Sinai School of Medicine were randomly assigned to a control group or an emotional content (EC) group for a sudden cardiac death management course. All subjects were monitored for heart rate and were assessed using the State-Trait Anxiety Inventory. Control group participants experienced an HFS in which actors were not scripted to add stress, whereas EC group participants were exposed to an emotionally charged environment using the same actors.

Participants across the two groups were well matched by resting heart rates, baseline anxiety and prior ACLS knowledge. The EC group participants experienced greater anxiety than controls (mean state anxiety score: 35.0 versus 28.2 [p<0.05]; average heart rate [HR]: 94.6 bpm versus 72.9 bpm [p<0.05]; maximum HR: 120.8 bpm versus 95.3 bpm [p<0.05]). Six months later, written test scores were similar, but the EC group participants achieved higher practical competency examination ('mega code') scores than controls (32.5 versus 25.0; p<0.05). Independent t-tests and Spearman rank coefficients were employed where applicable.

Simulation with added emotional stressors led to greater anxiety during ACLS instruction but correlated with enhanced performance of ACLS skills after this course. The quantitative and qualitative values of added stressors need further exploration, but these values represent important variables in simulation-based education.