The influence of the simulation environment on teamwork and cognitive load in novice trauma professionals at the emergency department: Piloting a randomized controlled trial

In the emergency department, teamwork is essential for delivering safe and effective care to patients sustaining traumatic injuries [1]. Teamwork can be defined as the interaction between professionals who work interdependently toward the same goal [2]. Teamwork has an individual and group component; it depends on each member's contribution and team behaviors [2]. Deficiencies in teamwork have been linked to delays and deviations from evidence-based care, placing trauma patients at risk of death and avoidable errors [3]. This suggests that professionals' knowledge and technical skills are insufficient during trauma resuscitation. Instead, healthcare trauma professionals should be able to work together under intense time pressure to deliver coordinated and efficient care to these vulnerable patients [1].

Interprofessional training is strongly recommended to enhance teamwork in traumatology [4]. This is particularly true for novices who often have had little exposure working with profession from other disciplines during their education. To this end, high-fidelity simulation—an interactive educational strategy—has become increasingly popular in trauma centers to develop teamwork skills, such as communication, leadership or situation monitoring [5]. Typically, simulation involves a scenario featuring a computerized manikin that mimics the physiological responses of a patient [6]. It includes a briefing to prepare and orient participants to the scenario and a debriefing where they reflect and discuss their individual and collective experiences afterwards [7]. Our recent systematic review shows that interprofessional high-fidelity manikin-based simulation enhances teamwork performance in trauma care in the emergency department [8].

High-fidelity manikin-based simulations can occur either in the clinical environment (in situ) or in a laboratory [8]. For trauma training, in situ simulations often happen directly in the resuscitation room, with the emergency department's equipment and contingents (e.g., noise and interruptions) [9]. In contrast, laboratory simulations are performed in a dedicated training space where educators control most environmental elements (e.g., equipment, personnel) [9]. From a practical point of view, in situ simulations involve more preparation and practicalities than laboratory simulations, e.g., scheduling according to patient volume, avoiding mixing equipment for care and training, and setting up the high-fidelity manikin in the resuscitation room [10], [11].

Despite these challenges, emergency department educators increasingly favor in situ simulation over laboratory simulation because it offers greater realism for teamwork training [8], [12]. However, the only two studies that explicitly compared in situ and laboratory simulation in pediatric and obstetric teamwork training do not support the added value of in situ over laboratory environments [13], [14]. Evidence instead suggests that a highly stimulating environment such as in situ simulation may interfere with participants' learning [15], [16], even more so for novice trauma professionals whose capacity to process new information is typically lower than experienced professionals [17], [18]. This phenomenon is associated with cognitive load—the load imposed on a learner's cognitive system when performing a task [19]. Cognitive load, which may run counter to the enthusiasm for in situ simulations, invites consideration of the effect of the simulation environment on teamwork and cognitive load. Conceptually, cognitive load provides insight into learning at the individual level and an opportunity to better understand its contribution to the development of teamwork skills.

To date, no study has compared the impact of the simulation environment on teamwork and cognitive load for novice trauma professionals. To answer such a question, a randomized controlled trial (RCT) is the research design that presents the highest level of internal validity. In education, RCTs are considered the gold standard for identifying an educational intervention that works and establishing a causal relationship between variables [20], [21]. This is because randomization reduces allocation bias and assures that participants’ characteristics in the two groups are probabilistically identical from the start—ensuring that any differences in outcomes are caused by the intervention [22]. However, RCTs are complex and require extensive conceptual, methodological, and practical planning. As we were designing a RCT, we quickly encountered several challenges concerning the preparation, implementation, and realization of such a study. For these reasons, we deemed that a pilot study was warranted to test the feasibility of our proposed research design before initiating a larger, full-scale RCT.

This pilot study aimed to test the feasibility of a RCT protocol to examine how the simulation environment (laboratory versus in situ) influences teamwork and cognitive load in novice trauma professionals at the emergency department. Specifically, the primary objective was to assess feasibility in three areas: (1) recruitment, attrition, and randomization of participants, (2) implementation of simulations in the appropriate environment (laboratory or in situ), and (3) data collection using individual (cognitive load, teamwork) and group (teamwork) measures. A secondary objective was to calculate effect sizes for the main study variables to provide insight into the results that could be obtained in a future RCT.

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