The effects of active (hot-seat) versus observer roles during simulation-based training on stress levels and non-technical performance: a randomized trial

Abstract

BackgroundActive ‘hands-on’ participation in the ‘hot-seat’ during immersive simulation-based training (SBT) induces stress for participants, which is believed to be necessary to improve performance. We hypothesized that observers of SBT can subsequently achieve an equivalent level of non-technical performance as ‘hot-seat’ participants despite experiencing lower stress.MethodsWe randomized 37 anaesthesia trainees into two groups to undergo three consecutive SBT scenarios. Eighteen ‘hot-seat’ trainees actively participated in all three scenarios, and 19 ‘observer’ trainees were directed to observe the first two scenarios and participated in the ‘hot-seat’ only in scenario 3. Salivary cortisol (SC) was measured at four time points during each scenario. Primary endpoint for stress response was the change in SC (ΔSC) from baseline. Performance was measured using the Anaesthetist’s Non-Technical Skills (ANTS) Score.ResultsMean SC increased in all participants whenever they were in the ‘hot-seat’ role, but not when in the observer role. Hot-seat ΔSC (mcg/dL) for scenarios 1, 2, and 3 were 0.122 (p = 0.001), 0.074 (p = 0.047), and 0.085 (p = 0.023), respectively. Observers ΔSC (mcg/dL) for scenarios 1, 2, and 3 were −0.062 (p = 0.091), 0.010 (p = 0.780), and 0.144 (p = 0.001), respectively. Mean ANTS scores were equivalent between the ‘hot-seat’ (40.0) and ‘observer’ (39.4) groups in scenario 3 (p = 0.733).ConclusionsObservers of SBT achieved an equivalent level of non-technical performance, while experiencing lower stress than trainees repeatedly trained in the ‘hot-seat’. Our findings suggest that directed observers may benefit from immersive SBT even without repeated ‘hands-on’ experience and stress in the hot-seat. The directed observer role may offer a less stressful, practical alternative to the traditional ‘hot-seat’ role, potentially rendering SBT accessible to a wider audience.Trial registrationClinicalTrials.gov Identifier NCT02211378, registered August 5, 2014, retrospectively registered.Electronic supplementary materialThe online version of this article (doi:10.1186/s41077-017-0040-7) contains supplementary material, which is available to authorized users.

A Mixed‐methods Comparison of Participant and Observer Learner Roles in Simulation Education

“…Limited studies have demonstrated the benefit of simulation observation; however, factors that affect observational learning have yet to be defined. To date, most simulation studies have had observers use structured observation tools, such as CA checklists, to activate them during the experience .…”

“…Kaplan et al., for example, demonstrated no learning differences between participants and observers; however, observer activation was augmented by the use of CA checklists to critique participant performance while watching the scenario unfold. Bong et al . promoted observer activation by having the observer believe that he or she might be called upon to assist within the scenario while observing directly in the patient encounter room.…”

“…Assessment periods with short intervals may not reflect the effect of knowledge and skills decay. Thus, short duration between testing periods may bias previous findings comparing scenario participation and observation . Stegmann et al., for example, had interval learning assessments only days after the educational intervention.…”

“…However, learning in their study was influenced by repetition of tested skills within curriculum, as well as learning within the larger pediatric emergency medicine fellowship, which included education on similar material. Additionally, Bong et al . demonstrated the equivalence of observational learning for nontechnical skills when compared with scenario participation; however, their study included repetitive education and a short, 3‐week interval assessment period.…”

“…To date, there is limited evidence to support that participation within scenarios is necessary for maximum learning and performance improvement. The educational benefit of simulation observation is therefore worthy of investigation . We hypothesized that the simple cognitive experience of considering clinical decisions, whether directly participating in a simulated scenario or not, benefits both observers and participants alike, particularly when paired with postevent debriefing.…”