Abstract
Background: Clinical simulation is currently a well-established methodology in healthcare education used for the acquisition of clinical skills and competence. Simulation has been adopted in emergency care training as a modality for teaching and assessment. Research shows that students experience increased stress and anxiety during simulation assessments due to the unique nature of these assessments which adds an element of socio-evaluative stress. The same socio-evaluative stress and anxiety may likely trigger self-doubt and interruptive thoughts that may interfere with the student’s performance as predicted by cognitive interference theory. Existing data on the impact of stress and anxiety on academic performance is equivocal, with some studies suggesting that stress and anxiety may enhance performance and some studies suggesting that they may have little effect or a negative effect on performance. Additionally, there is a dearth of literature regarding cognitive interference in the context of simulation assessments and its impact on performance. This study attempts to address this gap by investigating the relationship between stress, anxiety, cognitive interference and simulation assessment performance in emergency care students.
Methods: The study used a quantitative approach with a prospective longitudinal, observational design. Embedded within this was the before-and-after repeated measures design. Data was collected during simulation assessments from a sample of 64 emergency care students at the University of Johannesburg, and control data was collected on days when there were no assessments. State, trait and test anxiety were measured before and after simulation assessments along with cognitive interference. Physiological markers of stress were also measured in the form of blood pressure, before and after assessments, and heart rate variability, during assessments. Data analysis included a curve fitting procedure to establish which of the above variables significantly predicted simulation assessment performance and, following this, construction of a multivariate regression model.
Results: The study identified eight significant predictors of performance from the anxiety and cognitive interference variables; none of the physiological markers of stress significantly predicted performance. Post-assessment state anxiety, task relevant and task irrelevant thoughts were best described by a quadratic curve while
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post-assessment trait anxiety, pre-and post-assessment test anxiety and escapist thoughts were best described by an inverse linear relationship. The multivariate linear and quadratic regression models accounted for 8% and 14% of the variation in performance, respectively, suggesting the presence of other factors that significantly account for the variation in performance. The multivariate models exhibited high levels of multicollinearity and thus were limited in their ability to identify individual variables with predictive value.
Conclusion: Simulation assessments were associated with an increase in stress and anxiety, although physiologic markers of stress did not predict performance significantly. State, trait and one component of test anxiety along with the cognitive interference constructs of task-irrelevant and escapist thoughts significantly predicted simulation assessment performance suggesting an important role of both anxiety and cognitive interference in negatively affecting student performance in simulation assessments. These factors can, at least to some extent, be modified by cognitive behavioural interventions – an approach that has the potential to offset these negative effects.