CAEP FEI | Preparing for High Acuity Events – Stress Inoculation Training

In Education & Quality Improvement, Featured Education Innovations (FEI) by Chris HicksLeave a Comment

Raj is a first year resident who overhears that a trauma patient is being brought into the resuscitation bay. He races over and sees several people moving urgently to set up the room. The paramedics bring the patient into the room and quickly start telling him the history. Raj can feel the stress building within him and feels paralyzed and indecisive. After the shift, he wonders if there is a way for his training program to prepare him to deal with the acute high-stress experiences that he will encounter. 

The Emergency Department is often a high stress environment and it can be challenging to teach trainees to manage stress while providing effective patient care. This Feature Educational Innovation (FEI), titled “Preparing for High Acuity Events – Stress Inoculation Training” was originally posted by the CAEP EWG FEI Team on June 29, 2017 and answers the question: “How can we habituate team members to the deleterious effects of stress during acute high stress clinical events? A PDF version is available.

Description of the Innovation

What problem does this innovation solve?

Stress can have a profound impact, both positive and negative, on performance. Stress inoculation training is a paradigm trialed in the military and designed to habituate team members to the deleterious effects of acute stress on performance during high acuity, complex, high stress clinical events.


This innovation is a simulation-based intervention. It is based on stress inoculation training by using simulations to help team members habituate to stress. The innovation involves inter-professional education including Emergency Medicine Residents, General Surgery Residents, Emergency Medicine Nurses and Respiratory Therapists.

Necessary Resources

The required resources are nearly endless. This would require a multi-professional team to coordinate inter-professional simulation sessions, research associates to coordinate the investigative arm of the project, collaborators and confederates from nursing, respiratory therapy and local simulation centres.

The authors will will need to measure objective measurements of acute stress. These include heart rate variability, salivary cortisol, state-trait anxiety index, two-step cognitive appraisal tool, and team performance using an anchored behavioral rating scale.

What educational theories or conceptual frameworks does it utilize?

The innovation focuses on State-dependent learning, Transfer-appropriate processing and Reflective practice. 1–4

What is the current status of this innovation?

The innovators are currently nearing the end of the study. They hope to publish an abstract soon.

Bottom Line

Stress inoculation training is believed to be an important component of psychological skills training, inter-professional team training, and human factors for complex medical events. Debriefing teams based on emotions and their impact on performance poses unique challenges for simulation educators.

What techniques do you use to cope with high-stress clinical events?

How does your residency program prepare its trainees to manage high-stress clinical events?


More about CAEP FEI

This post was originally authored for the Canadian Association of Emergency Physicians (CAEP) Feature Educational Innovations project sponsored by the CAEP Academic Section’s Education Working Group and edited by Drs. Teresa Chan and Julien Poitras. CAEP members receive FEI each month in the CAEP Communiqué. CanadiEM will be reposting some of these summaries, along with a case/contextualizing concept to highlight some recent medical education literature that is relevant to our nation’s teachers.[bg_faq_end]


Leblanc V, Regehr C, Tavares W, Scott A, Macdonald R, King K. The impact of stress on paramedic performance during simulated critical events. Prehosp Disaster Med. 2012;27(4):369-374. [PubMed]
Saunders T, Driskell J, Johnston J, Salas E. The effect of stress inoculation training on anxiety and performance. J Occup Health Psychol. 1996;1(2):170-186. [PubMed]
Harvey A, Nathens A, Bandiera G, Leblanc V. Threat and challenge: cognitive appraisal and stress responses in simulated trauma resuscitations. Med Educ. 2010;44(6):587-594. [PubMed]
LeBlanc V, Bandiera G. The effects of examination stress on the performance of emergency medicine residents. Med Educ. 2007;41(6):556-564. [PubMed]
Chris Hicks

Chris Hicks

Dr. Christopher Hicks is an emergency physician and trauma team leader at St. Michael’s Hospital in Toronto. He is an Education Research Scientist at the Li Ka Shing Knowledge Institute.

Chirag Bhat

Chirag Bhat is an Emergency Medicine resident at the University of Ottawa. He has interests in medical education and toxicology. He is a basketball fan and cheers for the Toronto Raptors.