Stress response in the daily lives of simulation repeaters. A randomized controlled trial assessing stress evolution over one year of repetitive immersive simulations

Daniel Aiham Ghazali, Cyril Breque, Philippe Sosner, Mathieu Lesbordes, Jean-Jacques Chavagnat, Stéphanie Ragot, Denis Oriot, Daniel Aiham Ghazali, Cyril Breque, Philippe Sosner, Mathieu Lesbordes, Jean-Jacques Chavagnat, Stéphanie Ragot, Denis Oriot

Abstract

Background: Simulations in healthcare reproduce clinical situations in stressful conditions. Repeated stress exposure might influence the learning process in simulation as well as real-life.

Objectives: 1) To record heart rate and heart rate variability evolution during one-day simulation over one year; 2) To analyze the effect of repetitive high-fidelity simulations on the risk of post-traumatic stress disorder.

Study design: Single-center, investigator-initiated RCT. 48 participants were randomized in 12 multidisciplinary teams of French Emergency Medical Services to manage infant shock in high-fidelity simulations. In the experimental group, 6 multidisciplinary teams were exposed to 9 different simulation sessions over 1 year. In the control group, 6 multidisciplinary teams participated in only 3 simulation sessions, in common with those of the experimental group (initial, intermediate after 6 months, and finally after 1 year). Heart rate (HR) and heart rate variability (HRV) were analyzed on a 24-hour Holter from the day prior to simulation until the end of simulation. Questionnaires of Impact of Event Scale-Revised at 7 days and Post-traumatic Check-List Scale at 1 month were used to detect possible post-traumatic stress disorder in participants. p<0.05 was considered significant.

Results: Stress increased during each simulation in the two groups. After analysis on the 24-hour period, there was no significant difference between the two groups during the initial simulation session in terms of heart rate and heart rate variability. In the 24-hour period of the intermediate and final simulation sessions, the level of stress was higher in the control group during the diurnal (p = 0.04) and nocturnal periods (p = 0.01). No participant developed post-traumatic stress disorder after the 72 simulation sessions.

Conclusions: Despite the stress generated by simulation, the more the sessions were repeated, the less were their repercussions on the daily lives of participants, reflected by a lower sympathetic activity. Moreover, repetition of simulations did not lead to post-traumatic stress disorder.

Trial registration: ClinicalTrials.gov NCT02424890.

Conflict of interest statement

We have the following interests: The commercial company Laerdal (Tanke Svilandsgt 30. Stavanger, 4002. Norway) provided the SFMU with the amount of the grant. There are no patents, products in development or marketed products to declare. This does not alter our adherence to all the PLOS ONE policies on sharing data and materials.

Figures

Fig 1. CONSORT 2010 flow diagram.
Fig 1. CONSORT 2010 flow diagram.
Fig 2. Study design.
Fig 2. Study design.
HR: heart rate; HR: heart rate variability; IES-R: Impact of Event Scale–Revised; PCLS: Post-traumatic Check-List Scale. T0 to T7: times of HR and HRV analysis in addition to the analysis over 24-hour period.
Fig 3. Comparison of the evolution of…
Fig 3. Comparison of the evolution of HR and HRV with repeated simulation sessions in the experimental and the control groups pertaining to each and every one of the seven times T1 through T7.
Designated with a pink circle: Experimental group (n = 24) Designated with a blue circle: Control group (n = 24) HR: heart rate; LF/HF: LF/HF ratio (heart rate variability in frequency domain); RV: relative variation; T1: day prior to simulation; T2: before simulation; T3: during simulation; T4: after simulation; T5: before debriefing; T6: after debriefing; T7: 30min after debriefing. ANOVA was used to compare the evolution of HR and HRV in the two groups. F and p value are given for each comparison.
Fig 4. Evolution of IES-R and PCLS…
Fig 4. Evolution of IES-R and PCLS scores over time during the 9 simulation sessions in the experimental group and the 3 simulation sessions in the control group.
Designated with a pink circle: Experimental group (n = 24) Designated with a blue circle: Control group (n = 24) IES-R: Impact of Event Scale–Revised; PCLS: Post-traumatic Check-List Scale.

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