Performance Under Stress Conditions During Multidisciplinary Team Immersive Pediatric Simulations*
Authors: Ghazali Daniel Aiham , Darmian-Rafei Ivan , Ragot Stéphanie , Oriot Denis 
Published: February 2018

Objectives:
The primary objective was to determine whether technical and nontechnical performances were in some way correlated during immersive simulation. Performance was measured among French Emergency Medical Service workers at an individual and a team level. Secondary objectives were to assess stress response through collection of physiologic markers (salivary cortisol, heart rate, the proportion derived by dividing the number of interval differences of successive normal-to-normal intervals > 50 ms by the total number of normal-to-normal intervals [pNN50], low- and high-frequency ratio) and affective data (self-reported stress, confidence, and dissatisfaction), and to correlate them to performance scores.

Design:
Prospective observational study performed as part of a larger randomized controlled trial.

Setting:
Medical simulation laboratory.

Subjects:
Forty-eight participants distributed among 12 Emergency Medical System teams.

Interventions:
Individual and team performance measures and individual stress response were assessed during a high-fidelity simulation. Technical performance was assessed by the intraosseous access performance scale and the Team Average Performance Assessment Scale; nontechnical performance by the Behavioral Assessment Tool for leaders, and the Clinical Teamwork Scale. Stress markers (salivary cortisol, heart rate, pNN50, low- and high-frequency ratio) were measured both before (T1) and after the session (T2). Participants self-reported stress before and during the simulation, self-confidence, and perception of dissatisfaction with team performance, rated on a scale from 0 to 10.

Measurements and Main Results:
Scores (out of 100 total points, mean ± sd) were intraosseous equals to 65.6 ± 14.4, Team Average Performance Assessment Scale equals to 44.6 ± 18.1, Behavioral Assessment Tool equals to 49.5 ± 22.0, Clinical Teamwork Scale equals to 50.3 ± 18.5. There was a strong correlation between Behavioral Assessment Tool and Clinical Teamwork Scale (Rho = 0.97; p = 0.001), and Behavioral Assessment Tool and Team Average Performance Assessment Scale (Rho = 0.73; p = 0.02). From T1 to T2, all stress markers (salivary cortisol, heart rate, pNN50, and low- and high-frequency ratio) displayed an increase in stress level (p < 0.001 for all). Self-confidence was positively correlated with performance (Clinical Teamwork Scale: Rho = 0.47; p = 0.001, Team Average Performance Assessment Scale: Rho = 0.46; p = 0.001). Dissatisfaction was negatively correlated with performance (Rho = –0.49; p = 0.0008 with Behavioral Assessment Tool, Rho = –0.47; p = 0.001 with Clinical Teamwork Scale, Rho = –0.51; p = 0.0004 with Team Average Performance Assessment Scale). No correlation between stress response and performance was found.

Conclusions:
There was a positive correlation between leader (Behavioral Assessment Tool) and team (Clinical Teamwork Scale and Team Average Performance Assessment Scale) performances. These performance scores were positively correlated with self-confidence and negatively correlated with dissatisfaction.