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Reduced symptoms of anxiety among professional caregivers facing cardiac arrest after simulation based training

Abstract

Professional caregivers often suffer from post-traumatic stress disorder after intra-hospital cardiac arrest. The aim of our study was to describe long-term evolution of symptoms of anxiety among professional caregivers after a simulation-based training. Our study was a prospective, single-center pilot study conducted at Nancy-Brabois University Hospital. The sample included 56 professional caregivers, divided into two groups: 26 participants who underwent simulation-based training and 30 controls who did not participate during the study period. This sample size was determined based on the availability of participants and the exploratory nature of the pilot study. Each simulation involved a team of junior healthcare providers. Symptoms of anxiety and self-efficacy were assessed using standardized scales before, immediately after, and 3 months post-training. Control professional caregivers completed the same assessments without training. The symptoms of anxiety were assessed using the Spielberger State-Trait Anxiety Inventory (STAI) questionnaire while self-efficacy was assessed by Cardiopulmonary Resuscitation Self-Efficacy Scale (CPR-SES). Nine simulation-based training sessions were conducted, each including a team of professional caregivers (one junior physician, one junior nurse, and one care assistant). There was no significant difference in symptoms of anxiety immediately after training. However, after 3 months, both state and trait anxiety significantly decreased, while self-efficacy improved among the professional caregivers who attended the simulation-based training. Our study shows sustained behavioral improvements in professional caregivers after simulation-based training, enhancing their self-efficacy in cardiac arrest management. Further research is needed to evaluate the longevity and necessity of repeated training sessions.

Introduction

In-hospital cardiac arrest (IHCA) in Europe has an annual incidence between 1.5 and 2.8 per 1000 hospital admissions1,2 and nearly 300 000 patients suffer from IHCA each year in the United States3. Factors associated with survival are the initial rhythm, the place of cardiac arrest and the degree of monitoring at the time of collapse4. However, IHCA has a very poor prognosis with only 25% of survivors to discharge5. Thus, European Resuscitation Council Guidelines recommend that all hospital staff should be able to rapidly recognize cardiac arrest, call for help, start cardiopulmonary resuscitation and defibrillate within 3 min when appropriate4. Despite these recommendations, the management of IHCA remains improvable. Adherence to guidelines, such as refraining from epinephrine use before the second defibrillation in cases of refractory initial shockable rhythm, is suboptimal6. Moreover, more than one in four patients receive epinephrin before the first defibrillation, with an increase over time, from 20.8% in 2000 to 29.8% in 2018 and it was associated with lower survival and lower favorable neurological outcomes7. Also, substantial delays in defibrillation were reported (i.e., 18.6% of patients with a time to first defibrillation over 4 min), which is the primary treatment for patient with IHCA and shockable rhythm, arguing that efforts to train potential responders to IHCA are urgently needed7. In France, emergency procedure training is mandatory for all paramedics employed in public hospitals, with a strong recommendation to renew it every four years8. However, according to the American Heart Association (AHA) and the European Resuscitation Council (ERC), annual CPR training is recommended to ensure the retention of skills and knowledge over time. This training may involve simulation sessions, using low-tech models and is focused on the acquisition of technical gestures. Despite this, up to 10% of professional caregivers may experience post-traumatic stress disorder several weeks after the management of IHCA, with junior staff being most at risk of developing trauma symptoms regardless of the patient outcome9. Cardiopulmonary resuscitation simulation-based training is known as effective and may improve knowledge, product skill performance, time skill performance and patient outcomes10.

Self-efficacy, a concept introduced by Bandura, refers to an individual’s belief in their ability to perform actions necessary to achieve specific goals11. In the context of IHCA, it reflects the confidence of healthcare providers in recognizing cardiac arrest, initiating cardiopulmonary resuscitation, and using a defibrillator effectively. Essential for technical performance and emotional resilience, self-efficacy can be significantly enhanced through simulation, which provides a controlled environment to refine skills and prepare for critical situations.

Simulation plays a pivotal role in reducing symptoms of anxiety among healthcare professionals by exposing them to realistic and stressful scenarios within a controlled environment. By simulating emergency situations such as cardiac arrest, professional caregivers can gain increased self-efficacy, hone their skills, and develop more effective responses to critical events. Allowing participants to immerse themselves in practical scenarios, simulation provides a unique opportunity to overcome symptoms of anxiety associated with managing medical emergencies, thereby enhancing their emotional and cognitive preparedness in real-life situations. However, no specific study on the evolution of professionals’ anxiety at a distance from a simulation-based training on cardiac arrest is reported in the literature. Thus, the aim of our study was to describe long-term evolution of professional caregivers’ symptoms of anxiety and self-efficacy after a simulation-based training on IHCA.

Methods

Study design

This prospective case control pilot study was conducted in Nancy faculty of medicine and university hospital from May 3, 2022, to August 25, 2022. Nine simulation-based training sessions including each time a team of professional caregivers (i.e., one junior physician, one junior nurse and one care assistant), took place at the ‘University Center for Simulation-Based Education’ (CUESim). This study was funded by the Nancy-Brabois university hospital continuing education department.

Population

The population consisted of professional caregivers working in Nancy-Brabois university hospital as physicians, nurses, or care assistants. Each session included a team with one junior physician, one junior nurse (with less than one year of experience) and one care assistant usually working in the same department. We chose to train one person from each profession at the same time, to form a team as this is the most accurate representation of first responders to IHCA. All the medical departments located in Nancy-Brabois university hospital were asked to provide a team. Nurses and physicians had to have been graduated in the previous year while there was no experience limit for care assistants. Controls professional caregivers of the same professions (i.e., physicians, nurses, and care assistants) were included in the same medical department than participants. The group of professional caregivers included as “control” did not participate in the simulation-based training for this study. Their participation is planned once the study is completed.

Ethical considerations

All procedures were conducted in accordance with the ethical standards of the Declaration of Helsinki. For this type of study, French regulations provide provisions that may exempt from the requirement to obtain an ethical committee review (Law No. 2012 − 300 of March 5, 2012, concerning research involving the human person). All study participants were informed about the study, and we obtained their informed consent. Before enrolment, the researchers carefully explained the goals and methods of the study to the participants and their right to withdraw without affecting their course mark.

Endpoints assessments

The symptoms of anxiety among participants were assessed using the Spielberger State-Trait Anxiety Inventory for Adults (STAI-Y) questionnaire12. The STAI-Y, form Y, comprises two 20-item subscales: one measuring situational symptoms of anxiety (STAI Y-A), which relate to specific scenarios such as emergency medical situations, and another assessing generalized anxiety symptoms (STAI Y-B). A score of 40 or higher was used to define elevated anxiety symptomatology, as established by previous investigations (Appendices 1). The questionnaire was administered immediately before and after the simulation-based training session within the educational unit, as well as in person 3 months later.

Self-efficacy was measured using the Cardiopulmonary Resuscitation Self-Efficacy Scale (CPR-SES)13. This scale consists of 20 items presented on an eight-point Likert scale, based on Bandura’s self-efficacy theory14. The final score ranges from 20 to 160, with higher scores indicating greater perceived self-efficacy.

Participants were instructed to complete two questionnaires: the Spielberger State-Trait Anxiety Inventory for Adults (STAI-Y) to assess symptoms of anxiety and the Cardiopulmonary Resuscitation Self-Efficacy Scale (CPR-SES) to measure self-efficacy. These questionnaires were administered immediately before and after the simulation-based training session within the educational unit, and in person 3 months later. In contrast, participants in the control group voluntarily completed the questionnaires at their workplace.

Each team of participants was assessed, using a reproductible scale, on its technical ability to manage a cardiac arrest. The technical parameters assessed in this study were chosen based on their critical importance for effective CPR and adherence to resuscitation guidelines. While non-technical skills, such as communication and teamwork, are essential for optimal CPR management, they were not evaluated in this study as the primary focus was on technical skill acquisition. Future research will address the impact of simulation-based training on soft skills. The parameters assessed were the time taken to recognize cardiac arrest (defined as the time between effective cardiac arrest and first chest compression by the participants), the quality of cardiac massage assessed by the high-technology mannequin (i.e., depth and rhythm of chest compression, position of hands-on chest and no flow in compressions apart from defibrillation), the time before the first electric shock between effective cardiac arrest and first defibrillation, the time and quality of the emergency call (essential information provided by participants) and drugs management (injection of intravenous adrenaline at the correct dosage after the third defibrillation). We used the scale described by Donoghue et al., adapted to our simulation scenario15. Thus, the maximum score was 42 points.

Simulation session

The simulation-based training took place in a dedicated simulation room equipped with a high-technology mannequin (SimMan 3G + Laerdal) with audio and video recording, located in the faculty of medicine in Nancy. A 15-min briefing took place before the role-play, including a non-technical briefing followed by a technical briefing to promote the psychological and emotional safety of professional caregivers. The unique scenario involved the three participants (one physician, one nurse and one care assistant) confronting a 65-year-old man hospitalized in the ward, experiencing sudden cardiac arrest with shockable rhythm. The evolution was a return to sinus rhythm after three shocks. The scenario required one facilitator (intensivist) and was supervised by two session leaders. Session procedure is shown in Fig. 1. A structured debriefing was held after each scenario adapted from the Promoting Excellence and Reflective Learning in Simulation (PEARLS), with professional caregivers and facilitator16. At the end of the debriefing, the technical skills related to the scenario were reproduced on the mannequin with the learners and the training team, to demonstrate the optimum gestures to be performed. The entire simulation session lasted two hours per team.

Fig. 1

figure 1

Simulation session procedure.

Full size image

Data collection

Demographic and job-related data were collected before the simulation-based training (i.e., age, sex, profession, year of graduation, history of confrontations with a life-threatening emergencies and cardiac arrests). STAI-Y questionnaire and self-efficacy scale were performed before and after the session. All questionnaires were resubmitted to participants 3 months after the session by visiting them in their respective departments. The same questionnaires were also completed by the controls. Technical performance to manage IHCA could not be assessed in the controls because they were not confronted with the situation.

Statistical analysis

The number of participants (N = 56) in this pilot study stems from our preliminary approach, where the choice of the number of participants was determined empirically to assess the initial effects of simulation-based training on professional caregivers’ anxiety. All quantitative variables are shown as the means and standard deviations and qualitative variables as numbers and frequencies. Non-parametric tests were used when data distribution was not normally distributed: Mann-Whitney test for unpaired groups and Wilcoxon matched-pairs signed rank test for paired groups. Results with p value less than 0.05 (p < 0.05) were considered statistically significant. All the graphs, calculation and statistical analyses were performed using GraphPad Prism software version 8.0 for Mac (GraphPad Software, San Diego, CA, USA).

Results

Description of the population at baseline

Fifty-six professional caregivers (n = 19 physicians, n = 19 nurses and n = 18 care assistants) from Nancy-Brabois university hospital were included from May 3, 2022, to August 25, 2022, and divided into two groups (i.e., n = 26 who took part in the simulation training and n = 30 controls). Baseline characteristics are presented in Table 1. Briefly, most professional caregivers were aged between 20 and 30 (n = 42, 75%) and were female (n = 43, 76.8%). All professional caregivers (n = 56, 100%) worked in a medical specialty department (i.e., Cardiology, Gastro-enterology, Hematology and Pulmonology). Most nurses and physicians had less than five years’ experience (n = 34, 89.5%).

Table 1 Description of baseline characteristics of the study population.

Full size table

Measurement of symptoms of anxiety

These data are available in Fig. 2. Trait anxiety in professional caregivers was not different before and right after the training simulation session (40.9 ± 8.9 points vs. 42.4 ± 8.7 points; p = 0.208). However, 3 months after the session, trait anxiety was significantly decreased (40.9 ± 8.9 points vs. 4.1 ± 8.6 points; p = 0.0002). There were no differences between controls and participants before the session (39.2 ± 11.4 points vs. 40.9 ± 8.9 points; p = 0.545). At month three, lower trait anxiety was recorded between controls and participants however without reaching statistical significance (39.2 ± 11.4 points vs. 34.1 ± 8.6 points; 0.065) (Panel A, Fig. 2).

Fig. 2

figure 2

Measurement of general symptoms of anxiety (Panel A), situational symptoms of anxiety (Panel B), and Self-Efficacy Scale (Panel C) in the Simulation Group (Before, After, and at 3 Months Post-Session) Compared to the Control Group (Without Simulation Session).

Full size image

State anxiety of participants was significantly improved 3 months after the training session versus baseline (55.4 ± 9.1 points vs. 41.2 ± 7.4 points; p < 0.0001). Controls had a lower score than participants before the session (48.6 ± 14.5 points vs. 55.4 ± 9.1 points; p = 0.045) (Panel B, Fig. 2).

Among the 26 experimental group participants, 15 participants had pre-simulation trait and state anxiety scores of 40 or above, a cut-off indicating elevated anxious symptomatology as established in prior studies17.

Results of 3-months follow-up showed that six (40.0%) of them had a score below 40 both in trait and state anxiety. 11 of the 15 (73.3%) participants with high trait anxiety score had a score below 40 at 3 months. 12 of the 25 (48.0%) participants with high state anxiety score had a score below 40 at 3 months.

Measurement of self-efficacy scale

Self-efficacy scale was similar between controls and participants before training session (105.5 ± 19.8 points vs. 105.9 ± 16.6 points; p = 0.932) but was significantly improved 3 months after the training session (105.9 ± 16.6 points vs. 125.9 ± 13.2 points; p < 0.0001) (Panel C, Fig. 2). There were no differences between physicians, nurses, and care assistants and no differences between the youngest staff and the other about symptoms of anxiety or self-efficiency scale whether before the simulation or 3 months afterwards (Table 2).

Table 2 Comparison of symptoms of anxiety and self-efficacy between junior participants and others.

Full size table

Measurement of training performance

In professional caregivers attending the training session, mean technical performance was 16 ± 2.1 points out of 42 points (38% of achievements were validated during the session). The highest score was 18 points while the lowest was 12 points.

Discussion

The main result of the present study is that a simulation-based training improved trait and state symptoms of anxiety as well as the self-efficacy of the various professional caregivers. The study results indicates that trait symptoms of anxiety in professional caregivers showed no significant difference before and immediately after the simulation-based training. However, 3 months later, participants exhibited a notable reduction in trait symptoms of anxiety. State symptoms of anxiety also markedly improved among participants at the three-month follow-up. Self-efficacy was similar between controls and experimental group participants before the session but significantly improved for experimental group participants 3 months later. The special features of our training were the small number of learners at each session (i.e., three), an expert simulation center with high technology mannequin and a debriefing focused on development of the main technical gestures.

Included population

The study population was made up of particularly young nurses and physicians while care assistants were older and more experienced. This is a faithful representation of the teams currently working in French hospitals and likely to be responding to in-hospital cardiac arrests. Indeed since the COVID-19 pandemic, many nurses have left, replaced by younger nurses just out of school18,19. Including young healthcare professionals was expected, as it is well known that post-traumatic stress states are more frequent and more intense in young graduates9. However, there were no differences between junior staff and the other about symptoms of anxiety or self-efficiency whether before the simulation or 3 months afterwards (Table 2). This may be explained by the fact that the sessions were carried out by a team of professional caregivers working in the same department, which could help to reduce the symptoms of anxiety of youngers when they are supported by more experienced colleagues. Participants were recruited on a voluntary basis, which may encourage greater motivation and better learning. However, it was observed that the experimental group included professional caregivers with higher state anxiety scores than the control group prior to the simulation session, potentially explaining the significant difference in pre-simulation anxiety levels. Moreover, some controls had CPR management experience (management of more than ten cardiac arrests), which may explain the difference in state symptoms of anxiety between controls and participants before the simulation (Panel B, Fig. 2).

Endpoints assessments

We chose to evaluate symptoms of anxiety and self-efficacy among professional caregivers as these factors are critical to their ability to perform effectively in high-stress scenarios such as cardiac arrest management. Simulation-based training aims to reduce situational anxiety and improve self-efficacy, thereby preparing caregivers to handle real-life emergencies with greater confidence and competence. The three questionnaires used have been widely validated in the literature, particularly in the assessment of symptoms of anxiety and self-efficacy in professional caregivers20,21,22. Studies also shown that STAI questionnaire is a sensitive predictor of caregiver’s distress over time, that it can vary with changes and has a robust internal consistency (α = 0.92)23,24. CPR-SES aimed to assess the sense of self-efficacy in a particular situation of cardiopulmonary resuscitation, which is defined as an individual’s belief in his ability to cope with this situation.

Self-efficacy significantly improved 3 months after the simulation-based training. This can be explained by the inclusion of a fifth simulation phase with time dedicated at the end of the session to personalized learning of the various technical procedures involved in cardiac arrest (i.e., chest compression, airway management, drugs management). As the questionnaires were completed by the professional caregivers in their place of work (i.e., in situ), this enabled symptoms of anxiety and self-efficacy to be accurately assessed in their usual professional behavior. Thus, the improvement in these parameters by the proposed simulation-based training corresponds primarily to level 1 of the Kirkpatrick model (reactions), reflecting participants’ perceptions of reduced anxiety and improved self-efficacy. Further studies should evaluate actual behaviors in clinical practice to confirm an impact at level 3.

Simulation training plays a vital role in preparing professional caregivers to effectively respond to cardiac arrest situations, as it enhances both technical and non-technical skills in a controlled environment25,26. It provides a realistic and controlled environment where clinicians can practice and refine their skills in a safe setting. Through simulation, healthcare professionals can gain hands-on experience in performing critical life-saving interventions such as cardiopulmonary resuscitation, defibrillation, and advanced cardiac life support protocols. By engaging in simulated scenarios, professional caregivers can develop and enhance their knowledge, clinical decision-making, teamwork, and communication skills. Simulation training allows for immediate feedback, debriefing sessions, and the opportunity to identify areas for improvement. It promotes confidence, competence, and readiness in managing cardiac arrest emergencies, ultimately leading to better patient outcomes and potentially saving lives.

Although high-technology tools, such as advanced mannequins, can sometimes evoke anxiety, their use in a structured and supportive simulation-based learning environment minimizes these potential stressors. By coupling high-fidelity simulation with small group sessions and tailored debriefings, this approach not only enhances technical skill acquisition but also builds confidence and emotional resilience among healthcare professionals, aligning with current evidence on best practices in medical education25,26.

Limits of the study

Our study has some limits. First, we did not assess symptoms of anxiety using objective physical measures, but we used validated questionnaires commonly used in medical simulation. Second, due to the low incidence and high mortality rate of in-hospital cardiac arrest, we were unable to assess the benefit of our training on patient survival. The limited number of participants (n = 56) in our study is attributed to its pilot nature. We embarked on this research as a preliminary step, and the choice of the number of participants was determined empirically to initially assess the effects of simulation-based training on professional caregivers’ anxiety symptoms. At this stage, it was not based on a formal evaluation of the required number to detect a significant difference. We are aware of the inherent limitation of this sample size, and we plan to further explore this issue in subsequent studies using a more comprehensive methodology to determine the optimal number of participants. Currently, we do not have specific data on the number of participants assessed in similar studies. Additionally, the use of a convenience sample in this study limits the generalizability of its findings.

Conclusion

In conclusion, the present study is the first to indicate a long-term improvement in professional caregivers’perceptions, specifically their symptoms of anxiety and self-efficacy, following a simulation-based training session. Further research will be needed to assess the sustainability of these improvements and the possible need to repeat this training with the same caregivers.

Data availability

All data generated or analyzed during this study are included in this published article.

Abbreviations

IHCA:

In-hospital cardiac arrest

STAI:

Spielberger state-trait anxiety inventory

CPR-SES:

Cardiopulmonary resuscitation self-efficacy scale

PEARLS:

Promoting excellence and reflective learning in simulation

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Acknowledgements

The authors would like to acknowledge the participants of this training course and the Cuesim team - Nancy Faculty of Medicine and University Hospital for their support during this work. We also thank the practitioners who participated in the simulation sessions for their dedication and commitment to our study.

Author information

Authors and Affiliations

Service de Médecine Intensive et Réanimation Brabois, CHRU Nancy, Pôle Cardio-Médico-Chirurgical, University Hospital of Nancy-Brabois, Rue du Morvan, 54511, Vandoeuvre-les-Nancy, France

Thomas Klein, Antoine Kimmoun, Guillaume Granier, Bruno Levy & Simon Valentin

Faculté de Médecine, INSERM U1116 DCAC, 54511, Vandoeuvre-les-Nancy, France

Thomas Klein, Antoine Kimmoun & Bruno Levy

Service d’Anesthésie Réanimation de Chirurgie Cardiaque et Transplantation, CHRU de Nancy, Pôle Anesthésie Réanimation, University Hospital of Nancy Brabois, Rue du Morvan, 54511, Vandoeuvre-les-Nancy, France

Thomas Klein

Centre Universitaire d’Enseignement par Simulation - CUESim, Virtual Hospital of Lorraine, Faculty of Medicine, Midwifery and Health Professions, Université de Lorraine, 54000, Nancy, France

Hind Hani

Département Ressources Humaines et Affaires Sociales, Service Formation Continue, CHRU de Nancy, 54000, Nancy, France

Alain Viaux

Vascular Medicine Division, Rare Vascular and Systemic Autoimmune Diseases Regional Referral Center, CHRU-Nancy, Université de Lorraine, Nancy, France

Stéphane Zuily

Pôle des Spécialités Médicales/Département de Pneumologie, CHRU de Nancy, Université de Lorraine, Nancy, France

Simon Valentin

INSERM U1254 IADI, Université de Lorraine, Nancy, France

Simon Valentin

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Thomas Klein

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