Abstract
Background
Mental imagery, defined as the conscious experience of visualization without real sensory stimuli, has been shown to be effective in various disciplines, such as elite sports, music and surgery to enhance performance. The integration of mental imagery in the training of anesthesia residents, especially using validated cognitive aids, could enhance non-technical skills such as communication and leadership, which are crucial in emergency situations and technical skills. The aim of our study is to evaluate the effectiveness of this approach in improving the performance of first-year anesthesia residents during the management of cardiopulmonary resuscitation in high-fidelity simulation.
Methods
This is a prospective, comparative, multicenter study. Twenty-four novice anesthesia residents received initial training in cardiopulmonary resuscitation and were then divided into two groups, similar at the outset. The mental imagery group performed a guided mental imagery session based on a cognitive aid immediately after the initial training and repeated it autonomously 7 times during the following 6 months. The control group did not receive any additional educational intervention. Finally, each resident underwent an individual assessment in a high-fidelity simulation. The primary outcome, non-technical skills, was assessed using the Behaviorally Anchored Rating Scale (BARS), scored by two blinded raters on video recordings. Secondary outcomes included technical skills, assessed using the Acute Care Assessment Tools 1 score, and residents’ stress levels, measured immediately before the final assessment using the Stress Visual Analogue Scale.
Results
Twenty-four residents, 12 in each group, were assessed. The mental imagery group had a higher BARS score than the control group at 6 months (26.5 vs. 19.5, p = 0.039). There was no difference in technical skills. The mental imagery group had lower stress scores, although this was not statistically significant.
Conclusion
Mental imagery of a cognitive aid improved the non-technical skills of novice anesthesia residents during the administration of simulated cardiopulmonary resuscitation. These results suggest that mental imagery may be beneficial in anesthesia training. Further research with larger sample sizes is needed to confirm these findings.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12909-025-07782-8.
Keywords: Mental imagery, High-fidelity simulation, Cardiopulmonary resuscitation
Background
Cardiopulmonary resuscitation is a dynamic, high-stakes team situation. Successful management depends not only on technical skills, but also on the non-technical skills of those involved, such as communication, situational awareness, decision-making and teamwork. Training junior anesthesia residents to develop these skills is therefore a challenge.
According to Richardson, “mental imagery refers to all those quasi-sensory or quasi-perceptual experiences of which we are self-consciously aware, which exist for us in the absence of those stimulus conditions known to produce their true sensory or perceptual counterparts, and which may be expected to have consequences different from those of their sensory or perceptual counterparts“ [1]. Mental imagery is already considered a productive and cost-effective means of learning and improving the performance of elite athletes and musicians [2, 3].
In medicine, systematic reviews of the effects of mental imagery on surgical teams show benefits for technical performance [4]. Mental imagery is also effective in teaching surgical skills to junior residents in training. Souiki et al. [5] developed a surgical training program using mental imagery as a low-cost, low-risk tool to improve practical skills. By incorporating this technique into training programs, residents can safely and repeatedly refine their surgical skills without the logistical and financial constraints associated with physical model interventions or high-fidelity simulations [6].
Anesthesia residents are often faced with critical and inherently stressful situations. Effective thinking under stress is critical, and mental imagery can help improve this ability. In a critical care trauma situation, mental imagery based on Advanced Trauma Life Support (ATLS) protocols can lead to an improvement in team-based skills compared to traditional simulation-based trauma training when performed just prior to simulation [7].
No study has evaluated the effectiveness of mental imagery in training programs for a critical situation context, where management involves complex cognitive and decision-making processes rather than defined motor actions as in surgery. Knowing how to perform cardiopulmonary resuscitation is essential for an anesthesia resident. The speed and effectiveness of the intervention is crucial: every minute counts, as delays or errors can lead to irreversible brain damage [8]. The acquisition of non-technical skills such as leadership, communication and decision-making in emergency situations is particularly valuable during initial anesthesia training. Proper management of the people present and their actions saves valuable time and significantly improves patient outcomes.
Cognitive aids provide valuable support in critical situations in anesthesia and intensive care, offering easy-to-use, step-by-step, real-time solutions [10, 11]. Their progressive structure and ease of use make them particularly suitable for mental imagery [5]. In addition, these cognitive tools have been validated by experts, thus ensuring their reliability.
The aim of this study was to evaluate the effect of repeated mental imagery using a cognitive aid on the performance of novice anesthesia residents in a simulated cardiac resuscitation scenario. Our primary outcome was non-technical skills assessed by two blinded reviewers using the previously validated Behaviorally Anchored Rating Scale (BARS). Better training in these skills could lead to improved patient outcomes and improved resident preparedness.
Materials and methods
Study design and setting
This is a prospective study comparing a group exposed to an educational intervention (mental imagery) with an unexposed control group. The study was conducted from November 2023, to June 2024, in two French university hospitals. The CERAR (Ethics Committee for Research in Anesthesia and Intensive Care) approved the study under IRB number 00010254 − 2024–014. The study was conducted in accordance with the ethical principles of the Declaration of Helsinki (Ethical Principles for Medical Research Involving Human Subjects) and the CERAR Ethics Committee determined that no other approval was required. Written informed consent, revocable at any time, was obtained from each resident. This study is reported according to the SQUIRE-EDU [12].
Selection of participants
The study participants were first-year anesthesia residents of Reims and Nancy. They were included in the study if they volunteered and excluded if they did not.
Intervention
The study began with a free format simulation training day on cardiopulmonary arrest, conducted in each city for first year anesthesia residents. We ensured that each group performed asystole and ventricular fibrillation cardiopulmonary arrest scenarios, allowing the introduction of the associated French Society of Anesthesia and Intensive Care Medicine (SFAR) cognitive aids during debriefing [13].
The ‘mental imagery’ group underwent a 5-minute relaxation session based on breathing exercises known as ‘cardiac coherence’ at the end of the simulation session, followed by a guided mental imagery exercise using the SFAR cognitive aids for cardiopulmonary arrest based on an animated PowerPoint. They repeated this mental imagery with their eyes closed for 10 min. This was followed by a 5-minute relaxation session. Over the next 6 months, the residents in the study group were reminded by e-mail and telephone messages to repeat the mental imagery at home. In total, there were 7 reminders to repeat the mental imagery on days 2, 5, 9, 20, 36, 62 and 136. This protocol was based on the results of the review by Goble et al. [6].
Residents in the control group did not receive any additional educational intervention or reminders.
Study of the intervention
All study residents were then individually assessed 6 months after the initial training. The evaluation session included a high-fidelity simulation on SimMan manikins with a scenario of cardiopulmonary arrest due to ventricular fibrillation in a vascular surgery room (Supplementary file 1). All residents were previously informed of the subject of the evaluation.
Residents were videotaped with their consent, and two external raters, both anesthesiologists and simulation trainers trained in the use of the scoring tools, scored the videos blinded to resident groups. To calibrate the data collection process, the two raters viewed and scored two videos using the Behaviorally Anchored Rating Scale (BARS) and Acute Care Assessment Tools 1 (ACAT1) scores and were allowed to discuss their results. The raters were unaware of the ongoing study and did not know any of the study residents.
Outcome measures
All residents completed the Movement Imagery Questionnaire-Revised (MIQ-R) at baseline, validated in English by Hall and Martin [14] and then in French by Lorant et al. [15], to ensure that there were no differences in visuospatial ability between the two groups. We also asked residents in the final simulation session if they had participated in a real-life cardiac resuscitation during the 6-month study period.
Primary outcome
The primary outcome is the assessment of residents’ non-technical skills (NTS) during the management of a simulated cardiopulmonary resuscitation using the Behaviorally Anchored Rating Scale (BARS). This is a tool for assessing the NTS of anesthesia providers, including situational awareness, decision making, communication and teamwork, which has been validated during simulated critical events [16]. This score is based on 36 points, 9 per category of non-technical skills (supplementary file 2).
Secondary outcomes
Residents’ technical skills (TS) were assessed using the Acute Care Assessment Tools 1 (ACAT1), a 20-point score specific to cardiopulmonary arrest [17] (Supplementary file 3).
Residents’ stress levels were self-assessed on the day of the final evaluation, just prior to the high-fidelity simulation evaluation, using a stress visual analogue scale (VAS, [18]). We hypothesize that the mental imagery group may have lower stress levels as a result of increased confidence in their skills.
Statistical analysis
No sample size calculation was performed for this study; a convenience sample was used. Data are presented as median [min-max] for continuous data due to small sample size. Inter-rater agreement was assessed using the percentage of agreement and the corresponding intraclass coefficient for quantitative data. Comparisons between groups were made using the Mann-Whitney U test for independent samples. All tests were two-tailed and statistical significance was considered at p < 0.05. Statistical analyses were performed with SPSS software.
Results
Thirty students participated in the initial training, but 6 residents were unable to attend the final evaluation due to their hospital duties and were therefore excluded from the study (Fig. 1). Consequently, 24 students were analyzed, 12 in the control group and 12 in the mental imagery group.
Fig. 1.
Study design
The demographic characteristics of the residents are summarized in Table 1. The groups were comparable in terms of age, gender, baseline MIQ-R and exposure to real-life cardiac resuscitation during the study period.
Table 1.
Demographic data
| Control Group n = 12 |
« Mental imagery » Group n = 12 |
p | |
|---|---|---|---|
| Median Age (years) | 25 [24–32] | 25 [24–30] | NS |
| Sex (M, %) | 7 (58) | 7 (58) | NS |
| Baseline MIQ-R | 44 [31–56] | 43,5 [24–54] | NS |
| Real life cardiac resuscitation in the study period | 9/12 | 9/12 | NS |
Data are presented as median [min-max] or N (%)
Primary outcome
The results for the primary outcome are presented below (Fig. 2). The intra-class coefficient of concordance between the video ratings of the two raters was 0.69, indicating good agreement.
Fig. 2.
Results of primary outcome measures Box plot demonstrating the BARS (minimum score 0, maximum 36, 9 for each subcategory for the control and mental imagery groups). The central bar represents the median, the box represents the interquartile range and the whiskers the range
Secondary outcomes
Technical Skills (ACAT1)
No significant difference was found regarding the ACAT1 score between the two groups 15 in the mental imagery vs. 12 in the control group (p = 0,1).
Stress VAS
There was a noticeable trend in the stress VAS during the final evaluation simulation session. In fact, the mental imagery group had lower median stress VAS scores than the control group (5.5 vs. 6.5, p = 0.06).
Discussion
Our results suggest that repeating mental imagery based on a cognitive aid at a fixed interval over 6 months leads to improved non-technical skills in simulated cardiopulmonary resuscitation. We found a significant difference in the non-technical clinical performance in favor of mental imagery.
To our knowledge, this is the first study to demonstrate a positive effect of mental imagery training on non-technical skills in a critical care environment.
The benefits of mental imagery have been evaluated in anesthesia residents. In the study by Hayter et al., they evaluated a mental imagery warm-up immediately before a cardiac arrest simulation session. The mental imagery was guided by a script based on CRM principles and didn’t significantly improve the CRM performance of the anesthesia residents’ [19]. On the contrary, Lorello et al. found that 20 min of mental imagery based on an ATLS protocol immediately before a trauma simulation session led to an improvement in team-based skills [7].
Our study is the first to test the improvement in non-technical performance following mental imagery training according to the recommendations for standardizing mental imagery formats described in the meta-analysis by Goble et al. [6], which aimed to identify the necessary elements for a surgical training protocol using mental imagery. These recommendations included 5 min of relaxation before the mental imagery session and 5 min of refocusing after the mental imagery session. There is no consensus on the number of repetitions. The meta-analysis shows that the median number of sessions in trials where the intervention group outperformed the control group was 13. In our study, we chose 7 repetitions. In addition, as there was no consensus on the optimal interval between repetitions, we chose an interval that gradually increased in duration between repetition sessions.
Our intervention lasted 6 months, with the last repetition on day 136, one and a half months before the final assessment. Unlike the studies in the meta-analysis, our study examines the benefits of mental training over a longer period. Therefore, it will be necessary in the future to develop optimal models for intervals and number of repetitions in studies that aim to evaluate long-term retention, as in our case, over a 6-month period.
Thus, our study combined the use of mental imagery based on a cognitive aid such as Lorello et al. [7] and the use of this aid according to a training program and not simply as a pre-simulation warm-up as suggested by Goble et al. [6], and seemed to show interesting results. We can hypothesize that the clear and sequential structure of the cognitive aid, organized into distinct steps, may be a key element for mental imagery efficiency. Mental preparation of the precise sequence of steps in the cognitive sheet probably allowed residents to free up cognitive resources to focus on their environment. This is likely to have contributed to better role allocation and improved communication within the team, two crucial elements for effective management of emergency situations. By mentally ‘experiencing’ the situation, it may be possible to develop a better ability to anticipate and adapt.
Excessive stress negatively affects cognitive processes, particularly memory, attention and concentration [20]. Louridas et al. found an improvement in the performance of surgical trainees during a simulated laparoscopic jejunostomy interrupted by a stressful emergency situation among residents in the mental imagery group, in contrast to the control group [21]. Carrying out cardiopulmonary resuscitation, even in simulation, is stressful. Therefore, we can say that in our study, mental imagery improved non-technical performance in a stressful situation: thinking effectively under stress is crucial, and mental imagery may help to improve this ability. However, in our study, self-reported stress immediately before the simulation was lower in the mental imagery group, without reaching the limit of significance.
Limitations
Our study has several important limitations. The small sample size of 24 residents and the lack of randomization are major limitations. This limited number significantly reduces the statistical power of our results and limits their applicability to the broader population of anesthesia residents. A larger sample size would be required to confirm our observations and strengthen the external validity of the study.
The lack of preintervention performance testing is also a limitation because we cannot be completely sure that the level of the residents in the two groups was similar. However, it should be noted that the residents all started their anesthesia residency with the same training during their general studies, so it can be assumed that their level of knowledge and skills was quite comparable.
A further limitation is the lack of verification that the repetition of mental imagery was performed by the intervention group. Reminders were sent by email and text message, but we were unable to verify that residents actually undertook the training. We are only certain that each resident in the intervention group participated in the initial guided mental imagery. This may have an impact on the interpretation of our results.
Finally, the control group had no additional training. It is therefore possible that our results are related to the fact that one group repeated several times, while the other did not. However, the control group also knew the subject of the final assessment and had the opportunity to practice freely. In addition, the last mental imagery rehearsal was at a distance from the final assessment.
Conclusion
This study investigated the effect of repeated mental imagery using a cognitive aid on the performance of anesthetic residents during simulated cardiac resuscitation. Results suggest the pedagogical value of combining mental imagery and cognitive aids to improve the training of residents, particularly for the development of non-technical skills, which are essential to ensure the quality and safety of care in critical situations. This simple and low-cost approach has the potential to enhance real-world emergency preparedness and deserves integration into residency training programs.
However, further studies with larger samples are needed to confirm these conclusions. It will also be necessary to investigate generalization to more complex clinical situations and to refine the repetition intervals necessary for good retention to determine the overall effectiveness of this approach in clinical training.
Table 1. Demographic data.
Supplementary Information
Acknowledgements
Acknowledgements: The authors would like to thank the simulation teams of Reims and Nancy (CUESim) Universities who actively contributed to the study and who hosted us for the high-fidelity simulations, and all the voluntary participants.
Abbreviations
- ACAT1
Acute Care Assessment Tools 1
- BARS
Behaviorally Anchored Rating Scale
- CPR
Cardiopulmonary Resuscitation
- ICU
Intensive Care Unit
- MIQ
Movement Imagery Questionnaire
- MIQ-R
Movement Imagery Questionnaire-Revised
- SFAR
French Society of Anesthesia and Intensive Care Medicine
- VAS
Visual Analogue Scale
- VF
Ventricular Fibrillation
- VT
Ventricular Tachycardia
Authors’ contributions
Authors’ contributions: ML: participated in study design, student recruitment, simulation sessions, data analysis and interpretation, drafting and revising the manuscript and approved the final version.CD: participated in blinded analysis of the simulation sessions a posteriori and revising the manuscript and approved the final version.GA: participated in data collection analysis and interpretation, drafting and revising the manuscript and approved the final version.AB: participated in simulation sessions.TG: participated in simulation sessions.MS: participated in simulation sessions.PB: participated in blinded analysis of the simulation sessions a posteriori and revising the manuscript and approved the final version.DM: participated in study design, student recruitment, simulation sessions, data analysis and interpretation, drafting and revising the manuscript and approved the final version.
Funding
None.
Data availability
Data available on request (email of the corresponding author, data are small enough to be emailed under a excel media).
Declarations
Ethics approval and consent to participate
The study was approved by the CERAR (Ethics Committee for Research in Anesthesia Resuscitation) n° IRB 00010254 − 2024–014. All residents signed an informed written consent.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
Data available on request (email of the corresponding author, data are small enough to be emailed under a excel media).