Stress inoculation: a pilot study tracking the effect of regular simulation on pre-session anxiety amongst novice anaesthetists
Authors: Aldridge Matthew , Galbreath Jolene Slothouber , Steed Peter 
Published: November 2022

Effective simulation-based-education (SBE) relies on the use of psychological safety to encourage participants to adopt learning-orientated behaviours [1]. Excessive levels of anxiety or stress can present a challenge for establishing this psychologically safe container [2]. The idea of stress inoculation describes graded exposure to potentially anxiety inducing stimuli with the aim of enhancing performance by encouraging a state of ‘flow’ versus ‘freeze’ [3]. Potentially this could also improve the efficacy of SBE by reducing anxiety and improving psychological safety. We aimed to create a new SBE programme for novice anaesthetists in their first 3 months before starting on-call work. This was designed to create stress inoculation with frequent and regular SBE sessions, and we aimed to assess the impact of this change on pre-session anxiety levels.
This new SBE programme was delivered to the 5 novice anaesthetists at our institution over a 12-week period from February to May 2022 and consisted of weekly 30-minute SBE sessions. These were designed to fit with clinical commitments and minimise disruption to training in theatres, whilst following the ASPiH Standards Framework. Alongside weekly post-session evaluation (7-point Likert and free text), learners were asked to retrospectively rate their perceived pre-session anxiety levels from 1–10.
Overall feedback from the new programme has been consistently positive, particularly mentioning the benefits of a safe space for discussion, the open and supportive environment, and the benefits of learning from others’ experiences. One learner specifically credited the frequent nature of the sessions with an improvement in their confidence. Self-reported anxiety levels fell across subsequent early sessions (median anxiety score: week 1=4/10, week 3=2/10). Anxiety scores then peaked again at week 8 (median=5/10) before falling again. There was also significant inter-learner variability with one learner recording persistently higher anxiety scores.
This new format with regular short sessions appears to be very popular with excellent feedback. There is a reduction in self-reported pre-session anxiety with repeated frequent sessions. However, this is variable between individuals and across the placement, with an increase towards the end potentially reflecting anxiety about starting on the anaesthetic on-call rota. This demonstrates the importance of adapting SBE to both individual learners and the timing of a specific session within a wider SBE programme. Potentially routine evaluation of learner anxiety could allow a more tailored approach and further optimise individual learning.
1. Kolbe M, Eppich W, Rudolph J, Meguerdichian M, Catena H, Cripps A, Grant V, Cheng A. Managing psychological safety in debriefings: a dynamic balancing act. BMJ Simulation & Technology Enhanced Learning. 2020;6(3):164–171
2. Al-Ghareeb A, Cooper S, McKenna L. Anxiety and Clinical Performance in Simulated Setting in Undergraduate Health Professionals Education: An Integrative Review. Clinical Simulation in Nursing. 2017;13(10):478–491
3. LeBlanc, V, Posner, G. Emotions in simulation-based education: friends or foes of learning?. Advances in Simulation. 2022;7(3)