A simulation workshop to introduce coping skills

Experiencing clinical catastrophes can result in long‐lasting emotional and psychological impacts. In other fields, crisis simulation has been used to train professionals in coping skills.


| BACKGROUND
Experiencing one or more clinical catastrophes in the perioperative period is typical over a career in anesthesiology.This can result in a range of emotional and psychological impacts, 1 including anxiety, guilt, shame reactions, depression and more severe and long-lasting conditions such as posttraumatic stress disorder (PTSD). 2 Some organisational programmes have been established to support clinicians in the aftermath of such an event. 3However, despite the significant distress following perioperative catastrophe, and the almost inevitable experience of such an event, proactive formal training to enhance positive coping and resilience to stressful events is rare.
Eliciting realistic stress during clinical simulation is considered beneficial to learning. 4[8] Simulation can therefore support resilience after stress; resilience is the process and outcome of successfully adapting to difficult or Elizabeth M. Putnam and Kelcey J. Stratton contributed equally to the manuscript.
Work to be attributed to: Department of Anesthesiology and Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI, USA.challenging life experiences, including through mental, emotional and behavioural flexibility. 9Skills to support resilience can be taught, and several evidence-based approaches have been developed to enhance flexible coping through attention to social, cognitive and behavioural processes that promote recovery. 10Interventions associated with cognitive behavioural therapy (CBT) principles specifically address flexible coping by assisting individuals with identifying and modifying unhelpful negative beliefs related to stressful events, practising effective coping and building positive social connections. 11This approach is particularly relevant in medical training and professional development, given that self-critical thoughts, shame reactions, concerns about performance and social isolation may be common experiences among medical learners, particularly in response to challenging patient care or learning events. 12Many foundational CBT-based principles can be taught as a broad, self-directed skills, allowing individuals to incorporate strategies into their own routines and as an enhancement to their typical coping skills, without necessarily requiring the ongoing support of mental health professionals.Thus, coping skills training, applied to a stress-inducing simulation, presents an important and unique opportunity to help protect clinician well-being and promote resilience in their daily training and practice.
Even though learners know no harm can come to a plastic mannequin, simulation invokes physiological and psychological stress, and good debriefing acknowledges and addresses this.
We aimed to create a stressful simulated case, introduce the continuum of stress and potentially traumatic responses to anesthesiology residents and teach coping skills based in social, cognitive and behavioural theories of stress and resilience.

| APPROACH
Our workshop combined a simulated case with the introduction of coping skills.Each workshop comprised a small group of anesthesiology residents, facilitated by two clinical anesthesiology faculty, an education specialist and a clinical psychologist with expertise in PTSD and resiliency.See Figure 1 for timeline.
We briefed our learners explicitly establishing a psychologically safe learning space and outlining our educational goals and evaluations.The simulated scenario for the workshop was based on a peerreviewed case from Managing Emergencies in Pediatric Anesthesia (MEPA). 13It involved an occluded breathing circuit, which made ventilation impossible.The infant mannequin became hypoxemic, and then bradycardic, before we sent in a team member to suggest using a bagvalve-mask ventilation device, after which the infant fully recovered.
We chose this case because, whilst solvable, previous experience with MEPA has shown us participants rarely determine the real problem.
They typically fixate on reintubation, or on treating bronchospasm or pneumothorax, all of which prove futile.Previous participants typically have found the case emotionally impactful, even becoming close to tears, using phrases such as 'if this was real-life, he would have died', and recalling the simulation years later.
In this workshop, after the case, we began with a traditional debrief, which reviewed clinical and non-clinical points using a 'debriefing with good judgement' model. 5Next, a discussion on the range of responses to stressful events was initiated by the anesthesiologist, who disclosed a personal anecdote of a real-life clinical crisis and its impact.The clinical psychologist then addressed the cognitive, physiological and emotional aspects of the simulated scenario, inviting open discussion and normalising reactions.We then introduced coping skills, using the '4Rs' mnemonic, Recognise, Reflect, Reframe and Reach-out, based on principles of CBT 11 and the social-cognitive theory of stress and resilience. 14 introduced coping skills using the '4Rs' mnemonic: Recognise, Reflect, Reframe and Reach-out.
Recognise: Residents were encouraged to disclose their emotions around the simulation and identify negative selftalk and 'automatic thoughts'.
Reflect: We discussed how these 'automatic thoughts' might impact their emotional responses, perceived self-efficacy and social support.
Reframe: We demonstrated how to challenge those thoughts and provide a more realistic narrative of the situation that would help with processing in a more productive way, restore a sense of efficacy in a stressful environment and encourage growth and recovery.

Reach Out:
Residents were encouraged to contact trusted friends and colleagues, following a stressful event, emphasising the positive impact on resiliency of an established support network.
Take-home summaries and contact details for mental health support were provided at the close.

| Evaluation
We used a mixed methods evaluation approach, comprising three surveys and two 'check-in' questionnaires (Appendix S1); details of our quantitative and qualitative methodology and statistical analysis are described in Appendix S2.All residents participated in the workshop once during a 6-month period, and neither novices nor experienced anesthesiologists were overrepresented (Table 1).
Despite this, 87/96 (91%) strongly agreed the learning environment was psychologically safe.Residents reported strong baseline coping and social support resources, with a ceiling effect for PROMIS ES-SF scores.Perceived stress scale (PSS) scores were comparable to age and gender-matched norm groups and unchanged at 1-month followup.Experiencing a stressful event was common during the 1-month follow-up window, and residents' perception of their ability to manage the emotions of practice improved (see Figure 2).
F I G U R E 1 Programme, and collection timeline.

| Qualitative findings
The following three distinct themes were identified: (1) Scenario was stressful and elicited negative thoughts and emotional states; (2) descriptive language shifted from self-critical before the coping skills training to positive and team-focused afterwards; and (3) skills were in use at 1 month (see Table 2 for example quotes).A striking pattern across all evaluations was observed in which self-referencing comments tended to be more negative, whereas residents' positive comments were team focused.This suggested residents who reflected negatively about the scenario perhaps attributed their inability to resolve the simulation case to internal factors such as deficits in personal ability or knowledge.Those who reflected on it more positively typically referenced the team and appreciation for colleague support, which perhaps allowed for more self-compassion and less selfjudgement or isolation.Residents were more likely to reflect positively on their experiences following the coping skills training, suggesting a reframing of their experience to focus on colleague support might have deflected self-critical, negative comments.Indeed, several postworkshop comments described experiences of being 'grateful', 'comforted' and 'glad that other people could provide me with understanding and compassion'.

| IMPLICATIONS
This educational initiative was designed to offer residents practical strategies to enhance and reinforce their current coping resources and heighten awareness of potential responses to stress in the clinical environment.Learning and discussing these skills in the context of a challenging clinical simulation allowed the residents to immediately appreciate the applicability of these strategies.We promoted mental, emotional and behavioural flexibility, associated with key resilience processes, to encourage participants to consider ways in which they would approach real-world events that may elicit significant emotional distress and negative self-appraisals.
The notable immediate effect was a shift in residents' focus from negative and self-blaming, to more positive and team-focused after the workshop, which is consistent with CBT philosophy, where alterations in negative cognitions can shift perspective and improve mood and recovery after stress.Most residents were using the 4Rs after the workshop, which implies acceptance and relevance of the skills taught.The shift may result, in part, from the formal opportunity we provided for residents to access, explore and acknowledge or enhance their established coping skills.This exploration may have had an added benefit of minimising any potential shame responses experienced by the residents during this learning activity, by normalising their experiences, providing positive social engagement and support and emphasising their well-being and growth.Although we did not directly measure shame reactions, the residents' shift in comments from pre-to post-intervention is consistent with more flexible interpretations of their performance and abilities and reductions in the cognitive, emotional and physical experiences associated with selfjudgement and negative self-talk. 12In demanding clinical environments, it is often difficult for individuals and teams to find adequate time for reflection and recovery.By introducing an intentional practice (the 4Rs), our goal is to contribute to a culture of medicine that recognises clinicians' humanity and commitment to their work and normalise help-seeking and resources.
The notable immediate effect was a shift in residents' focus from negative, self-blaming to more positive and teamfocused after the workshop.
Limitations to our evaluation include the self-reported nature of the surveys, with follow-up limited to a single assessment at 1 month.

Paired data were not available for all residents and demographic
T A B L E 1 Demographic characteristics of participants in simulation session.diversity was limited.The unidimensional nature of Likert-scales limits more nuanced findings.We did not investigate how personal history interacted with perceived stress or coping skills.We provided the workshop in the context of a single simulation scenario; reproducibility has not been tested.
To the best of our knowledge, this is the first study of an initiative to combine psychologist-led coping skills teaching with existing clinical perioperative simulation, to specifically address social, cognitive and behavioural flexibility and positive coping.Many healthcare organisations have formalised programmes to respond to clinical catastrophes and support clinicians after the fact.Our workshop aligns with initiatives in other stressful occupations, where expert-led simulation interventions teach and reinforce coping skills pre-emptively and create opportunities for positive social support.This workshop has led to a widespread interest in coping skills across our department, with the introduction of a resiliency curriculum, talks for faculty and inter-F I G U R E 2 Pre-workshop and 1-month follow-up survey questions.Using the modified McNemar's test: standardised difference (post-pre) and corresponding 95% confidence interval, for the proportion of participants who responded Extremely well or Very well to How well do you feel you have dealt with a stressful event at work? were 0.
12 (0.06 to 0.18).With a p value of 0.0001, this increase was statistically significant.Qualitative categories and participant quotes.21%)usedwordslike 'anxious', 'stressed' or 'scared'.49/87(56.32%)reportedphysical stress including tachycardia and perspiration.15/87(17.24%)describedfeelings of inadequacy, disappointment, or guilt.'Shit!I'm not smart enough to do this'.'Goingthroughemotions even though I am just watching and even though this is a simulation' 'There is a sense of causing harm' 'What if this was real life?' Grateful for faculty and colleagues, Comforted by seniors experiencing similar thoughts, Glad that other people could provide me with understanding and compassion.Positive, change in perspective: Helpful to talk about how we cope with these issues, Not to beat myself up, practice the 4 Rs.More focused reflection rather than dwelling on negatives I have had to learn to control my first impulse in stressful events so that I don't do something without thinking Debriefing after helps to reflect and come up with strategies to use in future.15of87 (17.24%) no change in coping strategies.No changes: Honestly, kind of the same, can't really say that I'm now utilizing 'new' skills.It was nice to have the session to hear other people's stories but I'm not sure it really gave me new 'skills' or techniques.Took time to introspect about how I was handling it Spoke up and asked for time to reflect before being put in another room.Reframing and avoiding negative self-talk Being very honest about my mistakes and verbalizing that mistakes happen Reach out: I spoke with my attending about it and my spouse.Surrounded myself with fellow residents ACKNOWLEDGEMENTSThis work was funded in part by a grant from the Clinical Simulation Center at the University of Michigan, Ann Arbor, MI.The authors wish to thank Dr Raza Zaidi MD, Dr Prab Koppera MD and Dr T A B L E 2