The emotional and cognitive impact of unexpected simulated patient death: a randomized controlled trial

Chest. 2014 May;145(5):958-963. doi: 10.1378/chest.13-0987.


Background: Observational studies suggest that emotions experienced during simulation training may affect cognitive load and learning outcomes. The objective of this study was to manipulate emotions during simulation training and assess the impact on cognitive load and learning.

Methods: In this prospective randomized trial, 116 final-year medical students received training in a simulated scenario of a 70-year-old woman presenting with reduced consciousness due to aminosalicylic acid ingestion. Training groups were randomly allocated to one of two endings for the scenario: The patient was transferred to another service, or she experienced a cardiorespiratory arrest and died. Participants rated their emotions and cognitive load after training. Three months later, we evaluated their performance on a simulation Objective Structured Clinical Examination station of a 60-year-old man presenting with reduced consciousness due to ethylene glycol ingestion.

Results: Emotions tended to be more negative for students in training groups where the simulated patient died. These students also reported a higher cognitive load (mean ± SD, 7.63 ± 0.97 vs 7.25 ± 0.84; P = .03; d = 0.42) and were less likely to be rated as competent to diagnose and manage a patient with reduced consciousness due to toxin ingestion (OR, 0.37; 95% CI, 0.14-0.95; P = 0.04) 3 months later.

Conclusions: Students exposed to unexpected simulated patient death reported increased cognitive load and had poorer learning outcomes. Educators need to expose learners to negative experiences; therefore, further studies are needed on how best to use negative emotional experiences during simulation training.

Publication types

  • Randomized Controlled Trial

MeSH terms

  • Aged
  • Clinical Competence
  • Cognition / physiology*
  • Curriculum*
  • Death, Sudden, Cardiac*
  • Education, Medical, Undergraduate*
  • Educational Measurement
  • Emotions / physiology*
  • Female
  • Follow-Up Studies
  • Humans
  • Learning / physiology*
  • Male
  • Middle Aged
  • Patient Simulation*
  • Prospective Studies
  • Stress, Psychological / psychology*
  • Students, Medical / psychology*