Chest
Volume 145, Issue 5, May 2014, Pages 958-963
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Original Research
The Emotional and Cognitive Impact of Unexpected Simulated Patient Death: A Randomized Controlled Trial

https://doi.org/10.1378/chest.13-0987Get rights and content

Background

Observational studies suggest that emotions experienced during simulation training may affect cognitive load and learning outcomes. The objective of this study was to manipulate emotions during simulation training and assess the impact on cognitive load and learning.

Methods

In this prospective randomized trial, 116 final-year medical students received training in a simulated scenario of a 70-year-old woman presenting with reduced consciousness due to aminosalicylic acid ingestion. Training groups were randomly allocated to one of two endings for the scenario: The patient was transferred to another service, or she experienced a cardiorespiratory arrest and died. Participants rated their emotions and cognitive load after training. Three months later, we evaluated their performance on a simulation Objective Structured Clinical Examination station of a 60-year-old man presenting with reduced consciousness due to ethylene glycol ingestion.

Results

Emotions tended to be more negative for students in training groups where the simulated patient died. These students also reported a higher cognitive load (mean ± SD, 7.63 ± 0.97 vs 7.25 ± 0.84; P = .03; d = 0.42) and were less likely to be rated as competent to diagnose and manage a patient with reduced consciousness due to toxin ingestion (OR, 0.37; 95% CI, 0.14-0.95; P = 0.04) 3 months later.

Conclusions

Students exposed to unexpected simulated patient death reported increased cognitive load and had poorer learning outcomes. Educators need to expose learners to negative experiences; therefore, further studies are needed on how best to use negative emotional experiences during simulation training.

Section snippets

Participants

Participants were 116 final-year medical students at the University of Calgary (graduating class of 2011). We have a 3-year undergraduate curriculum of which the first 2 years comprise integrated systems courses and the final year is a clinical clerkship. This study took place during a simulation training session that was part of the clinical skills in clerkship curriculum, which runs throughout the clerkship year. The Conjoint Health Research Ethics Board at the University of Calgary approved

Effect of Unexpected Patient Death on Emotions and Cognitive Load

After debriefing on the simulation scenario, the mean subjective ratings for items assessing emotion tended to be lower (ie, more negative) for the training groups where the simulated patient died (Fig 2). The difference was significant for four of the eight items: nervous/relaxed (P = .04, d = 0.38), upset/contented (P < .001, d = 0.69), sad/happy (P < .001, d = 0.72), and depressed/elated (P = .008, d = 0.51). Participants in the training groups where the simulated patient died also reported

Discussion

The setting for this study was a simulation training scenario in which the learning objective was for final-year medical students to diagnose and manage a patient with an altered level of consciousness due to toxin ingestion. The study objective was, however, quite different from the learning objective. Instead, the research focus was on the impact of a negative emotional experience in the form of unexpected patient death on learning outcomes from a simulation training session. Although no

Acknowledgments

Author contributions: Dr McLaughlin had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Dr Fraser: contributed to the study design, data collection, and approval of the fi nal version of the manuscript.

Dr Huffman: contributed to the study design, data collection, and approval of the fi nal version of the manuscript.

Dr Ma: contributed to the study design, data collection, and approval of the fi nal version

References (30)

  • KA Ericsson et al.

    Expert performance: its structure and acquisition

    Am Psychol

    (1994)
  • K Fraser et al.

    The effect of simulator training on clinical skills acquisition, retention and transfer

    Med Educ

    (2009)
  • SM Alessi

    Fidelity in the design of instructional simulations

    J Comput Case Instr

    (1988)
  • GA Miller

    The magical number seven plus or minus two: some limits on our capacity for processing information

    Psychol Rev

    (1956)
  • JJG Van Merriënboer et al.

    Cognitive load theory in health professional education: design principles and strategies

    Med Educ

    (2010)
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    Funding/Support: The authors have reported to CHEST that no funding was received for this study.

    Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.

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