The Impact of Neonatal Simulations on Trainees' Stress and Performance: A Parallel-Group Randomized Trial

Pediatr Crit Care Med. 2017 May;18(5):434-441. doi: 10.1097/PCC.0000000000001119.


Objectives: Assess impact of neonatal simulation and simulated death on trainees' stress and performance.

Design: A parallel-group randomized trial (November 2011 to April 2012).

Setting: Sainte-Justine University Hospital, Montreal, Canada.

Subjects: Sixty-two pediatric trainees eligible, 59 consented, and 42 completed the study.

Interventions: Trainees performed two simulations where a term neonate was born pulseless. They were randomized to start with either survival (manikin responded to appropriate resuscitation) or death scenario (manikin remained pulseless despite resuscitation).

Measurements and main results: Performance was assessed using the Neonatal Resuscitation Program megacode score sheet by two reviewers. Subjective stress was assessed with a questionnaire. Three salivary cortisol (objective stress) values were compared: at baseline (T0: during lecture), presimulation (T1), and postsimulation (T2: after first scenario). Performance scores were similar in both groups in the first (83% vs 82%; p = 0.85) and second scenarios (82% vs 79 %; p = 0.87). Salivary cortisol levels at T0 (0.10 vs 0.10; p = 0.54), T1 (0.15 vs 0.11; p = 0.35), and T2 (0.23 vs 0.17; p = 0.23) did not differ between groups. Perceived stress level was six out of 10 in survival group versus seven out of 10 in death group (p = 0.19). Salivary cortisol increased significantly from T0 to T1 (p < 0.01). T2 cortisol levels were significantly higher than T1 (p< 0.001), yet this increase was not scenario dependent (p = 0.41) nor associated with performance on either scenario. Subscores for bag mask ventilation were lower than subscores for advanced resuscitation skills.

Conclusions: Neonatal simulations cause significant anticipatory and participatory stress. Despite this, trainees' performance score in simulation was over 80%. Simulated death did not impact performance, magnitude of rise in salivary cortisol level, and perceived stress level. Trainees performed better at advanced resuscitation skills (which are rarely needed) compared with basic skills routinely performed in practice.

Publication types

  • Randomized Controlled Trial

MeSH terms

  • Biomarkers / metabolism
  • Canada
  • Clinical Competence*
  • Female
  • Heart Arrest / therapy*
  • Humans
  • Hydrocortisone / metabolism
  • Infant, Newborn
  • Internship and Residency* / methods
  • Male
  • Manikins
  • Perinatal Death
  • Resuscitation / education*
  • Resuscitation / psychology
  • Saliva / metabolism
  • Simulation Training* / methods
  • Stress, Psychological / diagnosis
  • Stress, Psychological / etiology*
  • Stress, Psychological / metabolism


  • Biomarkers
  • Hydrocortisone