Cognitive appraisals and team performance under stress: A simulation study

Objective: The present study explored how challenge and threat responses to stress relate to performance, anxiety, confidence, team identity and team characteristics (time spent training and postgraduate experience) in a team-based medical simulation competition. Design: Cross-sectional data were collected prior to three days of competition. Setting: The study was conducted during a national simulation-based training event for residents, the SIMCUP Italia 2018. SIMCUP is a simulation competition where teams of four compete in simulated, medical emergency scenarios. Subjects: 95 participants from 24 teams. Measurements and Main Results: Each day prior to the competition, participants completed brief self-report measures which assessed demands and resources (which underpin challenge and threat responses to stress), cognitive and somatic anxiety, self-confidence and team identification. Participants also reported time (hours) spent practicing as a team and years of postgraduate experience. A team of referees judged each scenario for performance and assigned a score. We built a linear mixed model using demands and resources to model performance. The data showed that both demands and resources have a positive effect on performance (31 [11 - 50.3] p<0.01 and 54 [25 - 83.3], p<0.01 percentage points increase for unitary increases of demands and resources respectively), which however is balanced by a negative interaction between the two [demands * resources interaction coefficient = -10 [-16 - -4.2]. A high level of resources is associated with better performance until very high demands. Cognitive and somatic anxieties were found to be correlated with demands (Pearson’s r=0.51, p<0.01 and 0.48, p<0.01 respectively). Time spent training was associated with greater perceptions of resources (Pearson's r=0.36, p<0.01). Conclusions: We describe a model of challenge and threat that allows estimation of performance according to the perceived demands, resources and the interaction between the two. Higher levels of resources and lower demands were associated with better performance.