Threat and challenge: cognitive appraisal and stress responses in simulated trauma resuscitations

Abstract

OBJECTIVES Training and practice in medicine are inherently stressful. Research into the effects of acute stressors has revealed significant variability in individual responses to stressors, with performance impairments occurring in those who demonstrate elevated subjective and physiological responses. Cognitive appraisals (subjective assessment of situational demands and available resources) of a stressor have been proposed as a predictor variable in stress responses. However, the relationship between cognitive appraisal and stress responses has not been tested empirically in complex realistic situations. The purpose of this study was to determine the extent to which cognitive appraisal affects a medical trainee's subjective and physiological stress responses to high-acuity simulated clinical situations. METHODS Thirteen emergency medicine and general surgery residents participated in high (HS) and low (LS) stress trauma resuscitation simulations. Subjective (cognitive appraisal and State-Trait Anxiety Inventory [STAI]) and physiological (salivary cortisol) measures were collected at baseline and in response to participation in each scenario. RESULTS Post-scenario STAI scores, cognitive appraisal and cortisol levels were higher in the HS scenario compared with the LS scenario. For the participants who appraised the scenarios as 'threats' (in which the demands outweighed the resources), the ratio of perceived demands to resources was positively correlated with cortisol levels (r = 0.59, p < 0.05) and STAI responses (r = 0.64, p < 0.05). By contrast, for the participants who appraised the scenarios as 'challenges' (in which resources were sufficient to meet the demands), the perceived ratio of demands to resources was not correlated with either the STAI scores or cortisol levels. CONCLUSIONS Subjective appraisals of a situation appear to play an important role in stress responses, which have previously been shown to impair performance. As such, training for high-acuity events should include interventions targeting stress management skills.

Simulation fails to replicate stress in trainees performing a technical procedure in the clinical environment

“…The stress response is triggered when an individual assesses his or her resources to be insufficient to meet the demands of the situation (Harvey et al 2010). Socioevaluative stressors (when behaviour is potentially being judged by others) and situations beyond the perceived control of the participant are more likely to induce stress, and this may be relevant in formative and summative assessment.…”

“…Furthermore, it has been suggested that SBT may be used in stress management training (Arora et al 2009;Harvey et al 2010) for acute clinical scenarios.…”

The development and preliminary validation of the Challenge and Threat in Sport (CAT-Sport) Scale

“…Although this is a measure used in multiple studies examining challenge and threat (e.g. Feinberg & Aiello, 2010;Harvey, Nathens, Bandiera, & LeBlanc, 2010;Tomaka et al, 1993), it is subject to criticism. First, as Blascovich (2008) contends, when an individual evaluates sufficient or nearly sufficient resources to meet demands, challenge may arise as opposed to threat.…”

Is experimental research passé

“…(1) How people learn, how non-cognitive factors like motivation or stress (Harvey et al 2010) interact with learning, how individual differences like gender or ethnicity (see this issue) affect learning, how individual differences and teaching interact (Garg et al 2002;Levinson et al 2007), are subject of ongoing research and are an appropriately large share of the studies we do in education. (2) Educational outcomes are very diverse, and interventions that improve some outcomes may reduce others (e.g.…”