Stress and anxiety management strategies in health professions' simulation training: a review of the literature

Abstract

Introduction

Simulation training has been used to teach clinical skills to health profession trainees. Stress and/or anxiety occur in high-acuity scenarios in the clinical environment, and affect clinician performance and patient outcomes. To date, strategies that have been used in conjunction with simulation training for healthcare professionals that address stress management are limited. This paper reports a literature review conducted to explore strategies used with simulations to enhance the ability of health profession trainees in reducing acute stress and/or anxiety during high-acuity clinical events.

Methods

Databases searched included Scopus, PubMed, CINAHL, Web of Knowledge and Science Direct. The examples of the literature chosen were those published in the English language from January 2005 to March 2015, and were peer-reviewed empirical papers that focused on the strategies addressing stress and/or anxiety during simulation training for healthcare profession trainees.

Results

Eight studies using various forms of stress/anxiety management strategies with simulations demonstrated varying degrees of effectiveness. Themes that emerged from these eight studies were excessive stress and clinical performance in simulation, emotional training strategies in simulation, and factors contributing to stress and anxiety reduction during simulation.

Conclusions

Excessive stress and/or anxiety in the clinical setting have been shown to affect performance and could compromise patient outcomes. Health profession training curricula might benefit from a stress/anxiety reduction strategy integrated into the simulation programmes. This review showed that the stress/anxiety management strategies that have been used with simulations, mostly in surgical training, have various degrees of effectiveness.

Introduction

The symbiotic relationship between emotions and stress has been well documented.¹ It has been recognised that emotions can result in stress and, if not adequately managed, will consequently affect performance.^{2 3} Hence, in the milieu of clinical practice, a health professional's competence can be affected by emotional responses such as stress and anxiety.^4–7 Judgment mistakes may be indirect results of emotional states that cloud awareness, produce communication barriers, and produce the inability to cope with stress and fatigue,^{1 8} producing human factor errors. To achieve safe practice, technical and non-technical skills are both important from the human factors' perspective.⁸ Clinical performance is not only reliant on the technical skills of the clinician, as effective performance was shown to be associated with emotional intelligence and decision-making skills.⁹ Therefore, the link between emotions and performance cannot be denied. The need for a strategy to facilitate the integration of emotional training into clinical skills training has been highlighted in health professional education.³

To date, there is a paucity of strategies integrated into existing healthcare professions’ simulation programmes that aim to train stress and anxiety management. As many of the skills taught to healthcare professionals are mainly delivered by means of simulations, strategies that modulate stress in these realistic settings can be valuable in training. The aim of this review was to examine the existing literature on the strategies that have been integrated into simulation training, to reduce acute stress and/or anxiety among healthcare professionals during high-acuity clinical events. We also aimed to determine whether these strategies resulted in a reduction of learner stress as evidenced by stress/anxiety outcome measures.

Methods

A search of the published literature from January 2005 to March 2015 was conducted on the following databases: Scopus, PubMed, CINAHL, Web of Knowledge and Science Direct. The search terms used were (stress OR anxiety OR stress management OR stress reduction) AND (simulation OR healthcare simulation) AND (performance OR skills OR clinical performance) AND (doctors OR nurses OR healthcare professionals).

The initial database search retrieved 468 publications. The titles and abstracts of these articles were reviewed. Studies that were chosen were those published in the English language and were peer-reviewed empirical papers that focused on the strategies incorporated into health profession simulation training to reduce stress and/or anxiety. These studies should have outcome measures of stress and/or anxiety taken during simulation-based trainings. Articles with strategies for stress/anxiety reduction but with outcome measures taken during simulation-based assessments were not included. Twenty-six articles qualified for full-text review. Each article was assessed independently against the inclusion criteria, by a second reviewer. Appraisal of the retrieved articles' validity and relevance were appropriately guided by Young and Solomon's¹⁰ critical appraisal questions. After an assessment of the articles based on the established inclusion criteria, only eight publications were included in the review (see online supplementary table). The reference lists of these eight papers were also assessed for possible articles that fitted the review criteria. No new articles were found. Thematic analysis was conducted to evaluate the identified literature.¹¹ The generated themes were also confirmed by the other authors to ensure the rigour of the process. The themes are excessive stress and clinical performance in simulation, emotional training strategies in simulation, and factors contributing to stress and anxiety reduction during simulation.

Results

Excessive stress and clinical performance in simulation

Excessive levels of acute stress have been acknowledged as a critical factor that may adversely affect performance and compromise patient safety,^{6 12–17} particularly in high-risk environments and during crisis events.^{6 13} The operating theatre (OT) has been identified as one of the highly stressful areas in clinical settings,^12–14 and surgery was identified as a stressful specialty area.^12–16 Management of other critical events such as resuscitations have also been shown to elicit stress responses in healthcare professionals.^{6 17} All the studies included in this review recognised the presence of acute stress and/or anxiety in high-acuity scenarios and its possible negative effect on performance.^{6 12–18}

The recognition of acute stress during simulated high-acuity clinical events was demonstrated by the subjective outcome measures of stress and anxiety. Self-report measures such as the State-Trait Anxiety Inventory (STAI),^{12 13 15 16 18} the STAI X-1 S-Anxiety Form¹⁴ and perceived stress using a 10-point Likert scale¹⁷ provided data supporting stress recognition. A study by Andreatta et al¹⁴ found that the simulator tasks evoked feelings of anxiousness and frustration as a result of the need to perform well.

Studies on the evaluation of performance and stress showed that a certain amount of stress may affect performance in simulated environments,^{6 12–17} and technical skill performance was found to be inversely related to the amount of stress. Müller et al⁶ demonstrated that the participants' clinical performance was better when the crew resource management (CRM) intervention was initiated during stressful simulator training. The study by Andreatta et al¹⁴ showed that poor performance was related to ‘stepped-up’ or increasing levels of stress as measured by increased heart rates and stress-related behaviours. In a simulated surgical crisis, a stress management intervention was actually shown to be beneficial to surgical skills performance,¹³ suggesting that stress could reduce the quality of task performance in the OT setting. Similarly, other studies suggested that stress training showed an improving trend in performance and enhanced rapidity of arriving at a diagnosis.^{15 16} A stress management intervention that reduced the level of anxiety through progressive muscle relaxation was perceived by the participants as a valuable strategy for enhancing their thought process and improving their performance in communication skills.¹⁸ In all, stress has been subjectively and objectively measured, and excessive stress has been reported to have the potential to adversely affect clinical performance. It is therefore vital to consider the integration of stress and/or anxiety management into simulation training programmes.

Emotional training strategies in simulation

In a study by Andreatta et al,¹⁴ a ‘stepped-up’ sequence approach was utilised whereby pre-clinical medical students were initially trained to master their skills in simulation, followed by the addition of a stress element (observer). The study demonstrated that, by increasing the amount of stress elements, stress-related behaviours and heart rate could be increased, and these were found to be related to poor performance.¹⁴ The introduction of a stress element with the purpose of triggering an affective disruption was found to enable better stress management in trainees. This may imply that simulation training that addresses affective issues may help trainees to acquire stress management skills through practice.

The use of mental practice (MP) has been shown by one study as an effective strategy in decreasing stress in a sample of novice surgeons.¹² This strategy involved mental rehearsal after watching a live demonstration of a procedure together with the use of guided imagery and a procedure ‘script’. The study showed that the effectiveness of mental experience of a task during MP could translate into less stress on actual skill performance, and thereby suggested mental rehearsal as a form of stress inoculation.¹²

A combination of strategies has also proven to be beneficial in achieving stress reduction. Combined training on coping strategies, mental rehearsal and relaxation has been shown to increase coping skills and decrease participants' stress in the intervention arm of one study.¹³ In the study, participants were given knowledge on the procedural steps, instructions on surgical stress management strategies, mental rehearsal of the performance and practice tools on stress relaxation. All recipients of the combined interventions perceived an enhancement in their surgical stress management skills after the training. Likewise, stress training for surgical residents, consisting of self-awareness, focus, relaxation, positive self-talk, visualisation and team-building, has also been used with positive effects on anxiety levels and diagnostic skills.¹⁵ In a similar study by Maher et al,¹⁶ on the reduction of stress in surgical residents, a combined didactic and experiential curriculum focusing on individual stressor identification, stress management strategy identification and instruction, and application of stress management strategies (eg, relaxation, focus, visualisation and positive self-talk), was implemented. However, the study did not produce any significant stress reduction even though there was an improving trend in performance.¹⁶

Müller et al⁶ incorporated CRM training in simulations with the aim of training non-technical competencies to decrease stress. This training did not involve medical content and only emphasised the non-technical aspects of clinical performance. Although the intervention improved clinical performance scores and reduced stress levels, it had the same effect as the classical simulator training.⁶

A strategy that purports to increase affective realism by using high-fidelity simulation instead of low-fidelity simulation has also been used as an intervention to reduce stress in resuscitation scenarios.¹⁷ It is known that a certain degree of stress during training can improve performance and can decrease performance-related anxiety. However, the study did not demonstrate the effective use of high-fidelity simulation over low-fidelity simulation use in terms of stress modification.¹⁷

A stress management strategy using progressive muscle relaxation has been shown to reduce the anxiety of nursing students in clinical simulation to prepare them for actual clinical practice in the experimental group.¹⁸ Such a strategy was also perceived to clear thinking and improve cognition—processes that are essential to performance.¹⁸

In general, review findings demonstrated that various strategies, such as MP, structured stress reduction, training on coping, relaxation and progressive muscle relaxation, have been used in simulation trainings to enable health professions trainees, particularly physicians and nurses, to manage stress and anxiety during clinical events.

Factors contributing to stress and anxiety reduction during simulation

The degree of simulation realism has impact on the experience of the participants as regular simulation training enhances performance during stressful conditions.¹⁷ Furthermore, the addition of a seemingly authentic stress element, such as an observer's presence, allows for stress self-management.¹⁴ However, the use of high-fidelity simulation over low-fidelity simulation has not shown any significant difference in subjective stress measures nor in salivary cortisol levels.¹⁷ Although both high-fidelity simulation and low-fidelity simulation recreate the stress of an actual high-acuity event, neither is superior over the other.¹⁷

Stress and/or anxiety management, as a component of simulation training, conducted with a single intervention¹² or with a combination of strategies,^{13 15} has been shown to reduce stress. Repetitive simulation training, regardless of the type, may cause a decrease in stress as measured by physiological markers.⁶ This supports the premise that practice and overtraining reduce stress behaviour because the more the performer is familiar with his or her task's requirements, the less does stress affect performance.¹⁴

The results of a study by Müller et al⁶ suggested that a 1-day simulator training course can improve performance. Another study suggested that increasing the number of simulations can have more impact on levels of stress and performance in participants.¹³ Finan et al¹⁷ further noted that a study looking at the effects of repeated simulations, particularly focusing on resuscitation training, warrants further exploration.

Overall, factors such as realism and frequency or repetitions of the simulation-based strategy are key in designing a programme that will work in reducing stress/anxiety to a level that does not impair performance.

Discussion

It is evident that strategies attempting to reduce stress and anxiety have been incorporated into some simulation programmes. Integrating stress management in health professions' simulation programmes allows for achieving optimal performance in a highly critical clinical event. This is essential because healthcare professionals are continuously involved in patient care, and may be involved in highly stressful clinical situations.

Even though the studies included in this review primarily focused on physicians, these studies provided an overview of the strategies used in simulation training to manage stress and/or anxiety during critical clinical events, such as during surgical procedures and resuscitations. The review also looked at the merits of the strategies in terms of stress and/or anxiety reduction, and, to some extent, improved clinical performance. The findings from these studies were inconclusive on the effectiveness of the strategies. However, factors such as frequency and realism of the intervention may play a role in the effectiveness of stress management strategies in simulations. The application of MP, for instance, has been shown to reduce stress in novice surgeons performing laparoscopic cholecystectomies.¹² Further investigation is needed to determine if this strategy is also effective in reducing stress during a high-acuity event. MP benefit to expert clinicians must also be further evaluated. This is because the more experienced a clinician is in a skill, the less adversely does stress affect his/her performance.^{12 14}

The obvious necessity to train both skills and emotions during simulation training has some basis. In 2009, LeBlanc² noted that an increase in stress can impact performance. As such, it was suggested that health professionals should be taught stress management.² Simulation is an ideal environment for practising stress management as it provides a safe environment for learners to practise skills.¹⁹ As a training methodology, it also preconditions learners such that they can manage in actual clinical settings.²⁰ It is, however, noteworthy to highlight that simulation can also be a mode of assessment. Variations of simulation that have been used to assess learners, such as those incorporated in Objective Structured Clinical Examinations, have been reported as stressful and anxiety-provoking.^{21 22} Hence, stress generated by the simulation experience during training, which prepares learners for actual practice, differs from the stress inherent in assessments or examinations that use simulation.²³ Unlike in simulation training, where the goal is to inoculate learners to the stress of an actual environment to perform better, simulations used in assessments are fundamentally stressful, as how well or how badly learners perform is linked to their aspirations to progress or move up to the next level.²⁴

The data generated from the eight studies that used strategies in simulation training point to the growing awareness of stress and anxiety as possible predictors of performance and, ultimately, of patient outcomes. This observation is in agreement with evidence found in other literature acknowledging that stress and anxiety affect clinical performance.^{2 4 5 25} In the right amounts, stress can be a positive motivator, but in excessive amounts, stress can negatively impact performance.^26–28

Strategies for stress and anxiety management

Various strategies to reduce the stress and anxiety of participants in a simulation setting were used in eight of the studies included in the review.^{6 12–18} ‘Stepped-up’ sequencing¹⁴ supports that stress inoculation has the benefit of reducing anxiety and improving performance during stressful events.²⁹ Despite the premise that increasing fidelity is an important instructional design principle to enhance the transfer of simulation learning in actual clinical situations,⁶ increased fidelity by high-fidelity simulation utilisation¹⁷ may not necessarily make a significant difference on trainees' stress levels. Kneebone,³⁰ however, suggested that addressing emotion-related issues, such as stress associated with actual clinical practice, can make simulation training more effective. Hence, as added realism promotes the authenticity of a scenario, a more realistic intervention is expected to produce a more realistic amount of stress and thereby enable the trainees to better manage actual stress when they experience it.

CRM focusing on non-technical components during simulation debriefing has also been shown to modulate stress.⁶ This finding is consistent with the aims of CRM training that is meant to reduce human error.³¹ MP has also been shown to be effective in reducing stress and anxiety, as shown by Arora et al.¹² Although MP has been traditionally used to enhance performance, the confidence gained associated with improved performance may contribute to the decrease in stress and anxiety.³² A combination of strategies to reduce stress and/or anxiety for improved performance may have equivocal results. One stress management training package for surgeons proved to be beneficial as it tried to utilise coping techniques and a relaxation strategy to decrease stress and anxiety, combined with mental rehearsal to enhance performance.¹³ On the other hand, another combined-intervention study that utilised a didactic and experiential curriculum involving an educational component, relaxation, focus, visualisation and positive self-talk on surgical residents, did not result in any change in anxiety and stress levels.¹⁶ A similar study using self-awareness, focus, relaxation, positive self-talk, visualisation and team building, has shown to result in a decreasing trend for anxiety.¹⁵ Meanwhile, progressive muscle relaxation showed promise as a stress and/or anxiety reduction strategy when used in a group of nursing students in simulation.¹⁸ This finding is in agreement with other study results that show a reduction in anxiety after progressive muscle relaxation intervention in different patient populations.^{33 34} Further studies are needed to look into the effectiveness of these strategies.

There are several factors that need consideration when designing simulation programmes that include both physical and affective components of training. The studies included in the review showed that factors including degree of realism of the simulation,¹⁷ trainees' years of experience,^{12 14} number of interventions and types of exposure,^{6 13 15 16} and even the number of stressors incorporated into the simulation training,¹⁴ can contribute to the effectiveness of the strategy, either positively or negatively. It is therefore vital for these factors to be considered when designing a stress and anxiety management strategy that aims to help health professions trainees to better manage stress associated with critical clinical events.

Application to the education of health professions

Most of the studies included in the review looked at stress management strategies incorporated in simulations involving physicians. However, in the actual clinical setting, experience of these emotion-related concepts is not restricted to medical professionals. Often, critical clinical events involving stress and anxiety also affect nurses.³ Simulation provides a conducive setting to practise clinical skills and to engage participants such that similar emotional responses are elicited.³⁵ Hence, a simulation programme that incorporates skills’ teaching and stress management can be considered as a valuable component of health profession education.

Stress and/or anxiety management strategies would be of benefit to health profession trainees to better handle stress and anxiety during clinical practice. These strategies could be implemented as a part of simulations with variable complexity, spread throughout the course of health profession education. Strategies such as relaxation techniques, MP and increased realism of simulations can be gradually built into relevant modules in the curriculum. This integration will enable trainees to not only improve on their skills, but also to enhance stress/anxiety management abilities. Simulation training with the mentioned strategies could also be valuable for already practising healthcare professionals as part of their continuing education. This gives them the opportunity to deliberately practice clinical skills or competencies and manage stress at the same time to be more proficient.³⁶ Such a move will ensure not only competence on technical skills, but also the ability to manage stress and anxiety.

Conclusion

Healthcare professionals, such as physicians and nurses, perform skills and make decisions that impact on patient well-being. Stress and anxiety have been shown to affect the performance of skills not only in an actual clinical environment, but also in a simulation setting, as demonstrated by the reviewed studies. It is notable that the majority of the studies included in the review involved stress management strategies in simulation training for physicians. Critical patient-related events are regularly encountered by nurses and other healthcare professionals in various forms, such as during the performance of skills on challenging patients and in recognising critical patient events. Although the findings from the reviewed articles were equivocal, the integration of simulations with both technical and affective components into the health professions training curriculum has the potential to enhance clinical practice. However, based on the results of the review, further studies are needed on these stress management strategies in simulation. Future studies should also explore the type of strategies used for stress/anxiety management training, the use of such strategies in different healthcare professions and the translation of these strategies to effect improved clinical performance.