Beneria et al. BMC Medical Education (2020) 20:515 https://doi.org/10.1186/s12909-020-02427-4 RESEARCH ARTICLE Open Access Impact of simulation-based teamwork training on COVID-19 distress in healthcare professionals Anna Beneria1,2, Mireia Arnedo2, Sofia Contreras2,3, Marco Pérez-Carrasco2,3, Itziar Garcia-Ruiz2,4, Mónica Rodríguez-Carballeira2, Joaquim Raduà5,6,7,8 and Jordi Bañeras Rius2,9* Abstract Context: Non-technical skills such as leadership, communication, or situation awareness should lead to effective teamwork in a crisis. This study aimed to analyse the role of these skills in the emotional response of health professionals to the COVID-19 pandemic. Methods: Before the COVID-19 outbreak, 48 doctors and 48 nurses participated in a simulation-based teamwork training program based on teaching non-technical skills through simulation. In May 2020, this group of professionals from a COVID-19 referral hospital was invited to participate in a survey exploring stress, anxiety, and depression, using the PSS-14 (Perceived Stress Scale) and the HADS (Hospital Anxiety and Depression Scale) measures. A control group that did not receive the training was included. We conducted a logistic regression to assess whether having attended a simulation-based teamwork training program modified the probability of presenting psychological distress (PSS-14 > 18 or HADS> 12). Results: A total of 141 healthcare professionals were included, 77 in the intervention group and 64 in the control group. Based on the PSS-14, 70.1% of the intervention group and 75% of the control group (p = 0.342) had symptoms of stress. Having contact with COVID-19 patients [OR 4.16(1.64–10.52)]; having minors in charge [OR 2.75 (1.15–6.53)]; working as a doctor [0.39(0.16–0.95)], and being a woman [OR 2.94(1.09–7.91)] were related with PSS14 symptoms. Based on the HADS, 54.6% of the intervention group and 42.2% of the control group (p = 0.346) had symptoms of anxiety or depression. Having contact with COVID-19 patients [OR 2.17(1.05–4.48)] and having minors in charge [OR 2.14(1.06–4.32)] were related to HADS symptoms. Healthcare professionals who attended COVID-19 patients showed higher levels of anxiety and depression [OR 2.56(1.03–6.36) (p = 0.043)]. Conclusion: Healthcare professionals trained in non-technical skills through simulation tended towards higher levels of anxiety and depression and fewer levels of stress, during the COVID-19 pandemic. Keywords: COVID19 distress, Healthcare workers wellbeing, Simulation and teamwork * Correspondence: jbaneras@vhebron.net 2 Vall Hebron centre Simulació Clínica Avançada (VHiSCA), Direcció Docència, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain 9 Cardiology Vall d’Hebron Hospital Universitari, 08036 Barcelona, Spain Full list of author information is available at the end of the article © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Beneria et al. BMC Medical Education (2020) 20:515 Page 2 of 6 Background anxiety, and depression levels. The study was carried out On March 11, 2020, the World Health Organization de- in a single tertiary hospital. With the declaration of clared the severe acute respiratory syndrome coronavirus COVID-19 as a pandemic, our hospital became a 2 (SARS-CoV-2) outbreak a pandemic disease [1]. Emo- COVID-19 reference centre, admitting more than 2700 tionally traumatic experiences such as this pandemic can patients during the first two months. cause stress-related disorders [2, 3]. Indeed, we previ- ously reported that 65% of a Spanish sample of 5000 in- dividuals reported anxiety or depressive symptoms Participants during the COVID-19 outbreak [4]. All HP who had received an SBTT, 48 doctors and 48 Healthcare professionals (HP) are a high-risk popula- nurses from different medical specialties, were invited to tion group since they have faced a huge challenge and participate in a psychological survey and were designated psychological stress, anxiety, and depression from pan- as the intervention group (IG). The control group (CG) demics [5, 6]. Indeed, given the critical situation that we was built by inviting to participate 134 HP who had no are experiencing, HP who are directly involved in the contact with simulation training. diagnosis, treatment, and care of COVID-19 patients may develop symptoms related to psychological suffering that can trigger other mental health symptoms. Intervention courses The unique nature of intense working relationships in The Vall Hebron Advanced Clinical Simulation centre crises requires not only technical skills but also non- (VHiSCA), has conducted three editions (from Novem- technical competencies related mainly to leadership, com- ber 2019 to March 2020), of an SBTT instructor course, munication, and situation awareness [7]. To prepare 32 HP having participated in each one. The course had a people for these scenarios, simulation-based teamwork mixed design with a total of 25 h and was divided into training (SBTT) becomes an essential resource, since it online (13 h) and on-site practical part (12 h). As VHIS should help to develop the skill and competency of HP to CA has just started the formation with HP we had im- cope with the stress associated with emergencies and di- plemented it with medical practitioners and not with sasters [8]. Contexts of education and professional prac- delegates yet. The main objectives were to provide basic tice have profound effects on the substance and quality of knowledge on healthcare simulation, to provide skills to learning outcomes and on how professional competence be a simulation instructor, to acquire non-technical skills is expressed clinically [9]. SBTT offers learning in a safe management, and to master briefing and debriefing. container with a high-fidelity psychological environment, From our SBTT instructor course database we know without repercussion on the patient. In addition to train- that only 9% of the participants had taken a simulation ing non-technical skills, the acute stress responses in instructor course prior to the intervention. SBTT do not differ when comparing with real situations [10]. Besides, it has been observed that in simulation sce- narios, biological stress markers are detected [11] and that Stress, anxiety and depression instrument the performance of the team in stressful situations is a A Survey format was designed including two scales. The function of the non-technical skills of the leader [12]. This Hospital Anxiety and Depression Scale (HADS) [14, 15] suggests that simulation can be a powerful ally to prepare was applied to assess the level of anxiety and depression. HP for better coping in stressful situations, even showing The HADS has been widely used in the clinical setting a decrease in work stress levels in nurses from intensive and has been validated for the Spanish population [15] care units, keeping the positive effects at 6 months of and demonstrated an optimal internal consistency and follow-up [13]. test-retest reliability in the Spanish non-clinical popula- COVID-19 has become the biggest health crisis in de- tion [16]. It is composed of 14 items and evaluates 7 cades and has become a stressful context for HP. There is items for each dimension. In this study, scores > 12 were a lack of knowledge about the impact of an SBTT inter- considered positive for anxiety and depression domain vention on stress, anxiety, and depression levels in this [15]. A 12–15 cut-off could be appropriate for a non- health emergency. This work aims to study the effect of clinical population [16] with a sensibility and specificity an SBTT program on stress, anxiety, and depression levels of over 70% [17]. The Perceived Stress Scale-14 (PSS-14) during the onset of the COVID-19 crisis in HP. [18, 19] was used to evaluate stress. This scale has 14 items that evaluate stress perceived in the last month. Methods Both scales have already been used in studies with HP Study design [20, 21] and responded with a four-point Likert scale. This was a prospective observational cohort study to de- Based on previous literature [16, 18, 19] we analysed termine the effect of having received an SBTT on stress, groups with cut-off scores, HADS> 12 and PSS14 > 18. Beneria et al. BMC Medical Education (2020) 20:515 Page 3 of 6 Data collection and ethical approval Results After approval by the ethical committee of Vall d’Heb- A total of 141 HP completed the online survey, 77 ron University Hospital (PR (AG)261/2020), and within (80.2%) in the IG, and 64 (47.8%) in the CG. The demo- the third month of the pandemic, HP were invited to graphic characteristics of both groups are shown in participate in the study through corporate email. In- Table 1. formed consent was asked, and data was obtained an- In the IG, the HADS score mean was 14.23 (SD 7.41) onymously. The survey was first sent to the IG. To and in the CG was 12.08 (SD 6.66), mean difference − collect data for the CG, participants were asked to invite 2.15 (95% CI -4.52 – 0.22). Based on the HADS, 54.6% a co-worker with no experience in simulation to of the IG and 42.2% of CG (p = 0.346) had symptoms of participate. anxiety or depression. Significant differences were ob- served only in HP in contact with COVID-19 patients (p = 0.037) and having minors in charge (p = 0.033) Data analysis (Table 2). For the descriptive analysis, categorical data are shown PSS-14 score mean was 23.92 (SD 8.65) in the IG and as frequency and percentage, and differences between 24.33 (SD 9.00) in the CG, mean difference 0.41 (95% CI groups were analysed using the chi-square test. For con- -2.54 – 3.36). Based on the PSS-14, 70.1% of the IG and tinuous variables, normal distribution was tested by the 75% of the CG (p = 0.342) had symptoms of stress. Sig- Kolmogorov-Smirnov test; data following a normal dis- nificant differences were observed in HF in contact with tribution is shown as mean and standard deviation and COVID-19 patients (p = 0.003), having minors in charge differences were analysed using the Student’s t-test. (p = 0.022), working as a doctor (p = 0.038), and being a Effect sizes for continuous variables were analysed woman (p = 0.033) (Table 2). using the between-group mean difference (95% confi- Based on previous results, we performed a sub-analysis dence interval). Logistic regression was used to assess only with HP who had attended COVID-19 patients whether having attended the simulation-based teamwork (n = 88), 51 (58%) in the IG, and 37 (42%) in the CG training program modified the probability of having Healthcare professionals that had attended COVID-19 stress, anxiety, or depressive symptoms. The effects of patients showed higher levels of anxiety and depression sex, age, working with COVID-19 positive patients, hav- [OR 2.56 (1.03–6.36) (p = 0.043)]. (Table 3). ing minors in charge, being married and professional category were considered. Sub-analyses were performed Discussion based on exposure to COVID-19. The statistical signifi- This study provides results about the impact of an SBTT cance level was set at p < 0.05. Statistical software pack- program on stress, anxiety, and depression in HP during ages STATA 15.1 was used for all data analyses. a crisis. We found that in the IG when they were Table 1 Baseline demographic characteristics. Data were expressed as frequency (%) and mean (SD) Instructors (n = 77) Controls (n = 64) p Sex Female 54 (70.1%) 54 (84.4%) 0.047 Male 23 (29.9%) 10 (15.6%) Age (years) 41.9 (8.1) 38.5 (9.1) 0.020 Couple / married 39 (50.6%) 26 (40.6%) 0.234 Minors 45 (58.4%) 26 (40.6%) 0.035 Professional category 0.633 Doctors 38 (49.4%) 29 (45.3%) Nurses 39 (50.6%) 35 (54.7%) Workplace: COVID area 51 (66.2%) 37 (57.8%) 0.304 Contact with COVID-19 patients 0.282 Daily 42 (54.6%) 34 (53.1%) Weekly (> 1 day per week) 28 (36.4%) 19 (29.7%) Occasionally (< 5 days per month) 4 (5.2%) 3 (4.7%) Rarely 3 (3.9%) 8 (12.5%) Beneria et al. BMC Medical Education (2020) 20:515 Page 4 of 6 Table 2 Logistic regression of variables related with HADS > 12 significant results were found for stress and self-esteem and PSS14 > 18 between intervention and control group [25]. Odds Ratio (95% CI) p As in our study conducted in the general population HADS > 12 COVID-19 2.17 (1.05–4.48) 0.037 [4], we observed that individuals with minors in charge Minors in charge 2.14 (1.06–4.32) 0.033 and women had higher anxiety and depressive symp- toms. Besides, we also found that HP who worked with PSS14 > 18 COVID-19 4.16 (1.64–10.52) 0.003 COVID-19 patients had more symptoms of stress, anx- Minors in charge 2.75 (1.15–6.53) 0.022 iety, and depression, and women had more symptoms of Working as doctor 0.39 (0.16–0.95) 0.038 stress probably related to the working environment, Women 2.94 (1.09–7.91) 0.033 huge workload, long-term fatigue, infection threat, and frustration with the death of patients whom they care. There is evidence that healthcare simulation improves exposed to COVID-19 care patients, they suffered more healthcare performance and degree of retention of what anxiety and depression levels (HADS) than the HP who is learned when compared to all traditional teaching did not receive the education SBTT program. To our methods [26]. Our study results show that the emer- knowledge, this is the first study focusing on mental gency together with the knowledge of these abilities by health symptomatology on SBTT participants. part of the entire working group may be determining HP taking care of patients with COVID-19 are at risk factors for the psychological state of the skills previously of developing psychological distress and other mental trained by using SBTT. health symptoms [22]. Numerous psychiatric or psycho- Despite that, it is necessary to keep working on stress logical departments, psychological counselling centres, levels in HP during the simulation and in real settings. and university psychology units have launched special- Simulation educators need to create scenarios that pur- ized programs to attend HP in hospitals, through tele- posely change stress to enhance learning as it was found matics systems, telephone lines, and apps, to provide that psychological stress and anxiety is greater during psychological treatment in crisis. In this context, we simulation compared with hospital settings [27]. The found that HP who have received an SBTT program pre- intervention used is a faculty training programme rather sented more anxiety and depression when dealing with than a simulation based education programme for dele- COVID-19 patients. Firstly, higher perception and gates. Subsequent research should focus on studying the awareness levels are observed after SBTT [23], and usu- degree of distress that students present in crisis situations ally, these professionals are more involved and commit- based on the profile of the educator. Besides, health pro- ted in education tasks in hospitals, entailing otherwise fessions education programs must build student compe- more responsibility tasks. Another study found similar tencies in the affective domain of learning [28]. results showing a relationship between awareness atti- For this reason, it is crucial to be able to train profes- tude, anxiety experience, and perceived mental health sionals, promoting skills through SBTT that increases care needs in the community during the COVID19 pan- job security and reduces levels of distress generated in demic [24]. Secondly, collective efficacy was independ- crises, both in technical aspects (performing cardiopul- ently associated with flow in simulation practice, but no monary resuscitation, placement of line or tube, trache- ostomy, etc.) as in non-technical skills (communication, situational awareness, etc.) because stress triggers dis- eases and increases health resources. Table 3 Logistic regression of variables related to HADS> 12 and PSS14 > 18 between intervention and control group depending on the hospital area where they worked (COVID or No COVID). SBTT simulation-based teamwork training Strengths and limitations Odds Ratio (95% CI) p Study strengths are that it is the first study focus on stress, anxiety, and depression in simulation instructors COVID-19 after a pandemic, and it combined different new areas HADS> 12 Performance SBTT 2.56 (1.03–6.36) 0.043 never studied before, such as professional’s health and Working as doctor 0.35 (0.132–0.94) 0.038 simulation training after COVID-19. PSS14 > 18 Working as doctor 0.19 (0.06–0.60) 0.005 We acknowledge that our survey has several limita- No COVID-19 tions. Firstly, there is likely to have been a degree of HADS> 12 Minors in charge 4.25 (1.17–15.45) 0.028 selection bias in the CG. Secondly, the number sur- veyed varied greatly between the two groups. Thirdly, PSS14 > 18 Minors in charge 4.14 (1.21–14.12) 0.023 we cannot rule out the presence of residual Sex Female 5.74 (1.21–36.26) 0.63 confounders. Beneria et al. BMC Medical Education (2020) 20:515 Page 5 of 6 Conclusion 2. Ćosić K, Popović S, Šarlija M, Kesedžić I. Impact of Human Disasters and HP trained in non-technical skills as simulation instructor COVID-19 Pandemic on Mental Health: Potential of Digital Psychiatry. Psychiatr Danub. 2020;32(1):25–31. https://doi.org/10.24869/psyd.2020.25. had a tendency towards higher levels of anxiety and de- 3. World Health Organization; 1992. World Health Organization. Psychosocial pression and fewer levels of stress, during the COVID-19 consequences of disasters: Prevention and management. pandemic, being significant in the case of anxiety and de- 4. Fullana MA, Hidalgo-Mazzei D, Vieta E, Radua J. Coping behaviors associated with decreased anxiety and depressive symptoms during the COVID-19 pression in HP who directly attended COVID-19 patients. pandemic and lockdown. J Affect Disord. Published online 2020. https://doi. Studies with structured interventions, randomized con- org/10.1016/j.jad.2020.06.027. trolled trials, with larger homogeneous samples, can pro- 5. Lee SM, Kang WS, Cho AR, Kim T, Park JK. Psychological impact of the 2015 MERS outbreak on hospital workers and quarantined hemodialysis patients. vide more information. Therefore, more studies with Compr Psychiatry. 2018;87:123–7. these characteristics should be done before being able to 6. Zhang WR, Wang K, Yin L, Zhao WF, Xue Q, Peng M, Min BQ, Tian Q, Leng conclude the effectiveness of simulation-based techniques. HX, Du JL, Chang H, Yang Y, Li W, Shangguan FF, Yan TY, Dong HQ, Han Y, Wang YP, Cosci F, Wang HX. Mental health and psychosocial problems of Acknowledgements medical health workers during the COVID-19 epidemic in China. Psychother The authors are grateful to all the members of Teaching Department of Vall Psychosom. 2020;100053(45). https://doi.org/10.1159/000507639. d’Hebron Hospital Universitari and all the members of Comissió Técnica 7. Hu X, Chen H, Yu M. Exploring the non-technical competencies for on- Suport a la Simulació of Vall Hebron Advanced Clínical Simulation centre scene public health responders in chemical, biological, radiological, and (VHiSCA), specially CR, TA, SC, EA, MJ, LM, AB, DL, MdN, MJ. nuclear emergencies: a qualitative study. Public Health. 2020;183:23–9. https://doi.org/10.1016/j.puhe.2020.04.015. Authors’ contributions 8. Shrestha R, Kanchan T, Krishan K. Simulation Training and Skill Assessment All the authors have contributed to the intervention. AB, SC, MPC, IGR and JB in Disaster Medicine. In: StatPearls [Internet]. Treasure Island (FL): StatPearls have contributed to the design. MA, AB, SC and JB have contributed to Publishing; 2020. Available from: https://www.ncbi.nlm.nih.gov/books/ acquisition. MPC, IGR, AB, SC, MRC, JR and JB participate in the analysis and NBK551719/. [Updated 2019 Nov 28]. interpretation. All the authors have revised the work. They all agree to be 9. McGaghie WC, Issenberg SB, Petrusa ER, Scalese RJ. A critical review of accountable for all aspects of the work in ensuring that questions related to simulation-based medical education research: 2003-2009. Med Educ. 2010; the accuracy or integrity of any part of the work are appropriately 44(1):50–63. https://doi.org/10.1111/j.1365-2923.2009.03547.x. investigated and resolved. All the authors have read and approved the 10. Daglius Dias R, Scalabrini NA. Stress levels during emergency care: a manuscript. comparison between reality and simulated scenarios. J Crit Care. 2016;33:8– 13. https://doi.org/10.1016/j.jcrc.2016.02.010. Funding 11. Valentin B, Grottke O, Skorning M, et al. Cortisol and alpha-amylase as stress Authors have no affiliations with or involvement in any organization or entity response indicators during pre-hospital emergency medicine training with with any financial interest or non-financial interest in the subject matter or repetitive high-fidelity simulation and scenarios with standardized patients. materials discussed in this manuscript. Scand J Trauma Resusc Emerg Med. 2015;23(1):1–8. https://doi.org/10.1186/ s13049-015-0110-6. Availability of data and materials 12. Krage R, Zwaan L. Tjon Soei Len L, et al. relationship between non-technical The datasets used and/or analyzed the current study are available from the skills and technical performance during cardiopulmonary resuscitation: does corresponding author on reasonable request. stress have an influence? Emerg Med J. 2017;34(11):728–33. https://doi.org/ 10.1136/emermed-2016-205754. Ethics approval and consent to participate 13. El Khamali R, Mouaci A, Valera S, et al. Effects of a multimodal program This study was approved by the ethical committee of Vall d’Hebron including simulation on job strain among nurses working in intensive care University Hospital (PR (AG)261/2020). Informed consent was asked, and data units a randomized clinical trial. JAMA - J Am Med Assoc. 2018;320(19): was obtained anonymously. 1988–97. https://doi.org/10.1001/jama.2018.14284. 14. Zigmond A, Snalth R. The hospital anxiety and depression scale. Acta Consent for publication psychiatr. Scand. [revista en internet] 2014 [acceso 28 de noviembre de Not applicable. 2019]; 64(5): 361-370. Acta Psychiatr Scand. 1983;67(6):361–70. https://doi. org/10.1093/occmed/kqu024. Competing interests 15. Terol-Cantero M, Cabrera-Perona V, Martín-Aragón M. Hospital anxiety and No additional financial or other affiliation relevant to the subject of this depression scale (HADS) review in Spanish samples. An Psicol. 2015;31(2): article is reported. 494–503. https://doi.org/10.6018/analesps.31.2.172701. 16. Terol MC, López-Roig S, Rodríguez-Marín J, Martín-Aragón M, Pastor MA, y Author details Reig MT. Propiedades psicométricas de la Escala Hospitalaria de Ansiedad y 1 Estrés (HAD) en población española. Ansiedad y Estrés. 2007;13(2–3):163–76. Departament Psiquiatria, Vall d’Hebron Hospital Universitari, Barcelona, Spain. 2Vall Hebron centre Simulació Clínica Avançada (VHiSCA), Direcció 17. Torres-lagunas MA, Vega-morales EG, Vinalay-carrillo I. Universitaria Docència, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Validación psicométrica de escalas PSS-14 , AFA-R , HDRS , CES-D , EV. en Hospital Campus, Barcelona, Spain. 3Servei de Medicina Intensiva, Vall puérperas mexicanas con y sin preeclamsia. 2015;12(3):122–33. d’Hebron Hospital Universitari, Barcelona, Spain. 4Unitat Medicina Materna i 18. Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Fetal, Department d’Obstetrícia, Vall d’Hebron Hospital Universitari, Health Soc Behav. 1983;24(4):385–96. https://doi.org/10.2307/2136404. Universitat Autònoma de Barcelona, Barcelona, Spain. 5Institut 19. Trujillo HM, González-Cabrera JM. Psychometric properties of the Spanish d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain. version of the perceived stress scale (PSS). Psicol Conductual. 2007;15(3): 6 CIBERSAM, ISC-III, Madrid, Spain. 7King’s College London, London, UK. 457–77. 8 Karolinska Institutet, Stockholm, Sweden. 9Cardiology Vall d’Hebron Hospital 20. Franco JC. Reducción de los niveles de estrés y ansiedad en médicos de Universitari, 08036 Barcelona, Spain. Atención Primaria mediante la aplicación de un programa de entrenamiento en conciencia plena (mindfulness). Aten Primaria. 2010; Received: 12 August 2020 Accepted: 6 December 2020 42(11):564–70. https://doi.org/10.1016/j.aprim.2009.10.020. 21. Paiva CE, Martins BP, Paiva BSR. Doctor, are you healthy? A cross-sectional investigation of oncologist burnout, depression, and anxiety and an References investigation of their associated factors 11 medical and health sciences 1. Cucinotta D, Vanelli M. WHO declares COVID-19 a pandemic. Acta Biomed. 1117 public health and health services 17 psychology and cognitive Scie. 2020;91(1):157–60. https://doi.org/10.23750/abm.v91i1.9397. BMC Cancer. 2018;18(1):1–11. https://doi.org/10.1186/s12885-018-4964-7. Beneria et al. BMC Medical Education (2020) 20:515 Page 6 of 6 22. Neto MLR, Almeida HG, D’arc Esmeraldo J, Nobre CB, Pinheiro WR, de Oliveira CRT, da Costa Sousa I, Lima OMML, Lima NNR, Moreira MM, Lima CKT, Júnior JG, da Silva CCL. When health professionals look death in the eye: the mental health of professionals who deal daily with the 2019 coronavirus outbreak. Psychiatry Res. 2020;288(April):2–4 https://doi.org/10. 1016/j.psychres.2020.112972. 23. Chang AL, Dym AA, Venegas-Borsellino C, Bangar M, Kazzi M, Lisenenkov D, Qadir N, Keene A, Eisen LA. Comparison between simulation-based training and lecture-based education in teaching situation awareness: a randomized controlled study. Ann Am Thoracic Soc. 2017;14(4):529–35 https://doi.org/ 10.1513/AnnalsATS.201612-950OC. 24. Roy D, Tripathy S, Kumar S, Sharma N. Study of knowledge, attitude, anxiety & perceived mental healthcare need in T Indian population during COVID- 19 pandemic. Asian J Psychiatr. 2020;51:1–7 https://doi.org/10.1016/j.ajp. 2020.102083. 25. Kim MY, Park S. Associations of stress, self-esteem, and collective efficacy with flow in simulation among nursing students: a descriptive cross- sectional study. Nurse Educ Today. 2018;71:193–7 https://doi.org/10.1016/j. nedt.2018.09.03. 26. Okuda Y, Bryson EO, DeMaria S Jr, et al. The utility of simulation in medical education: what is the evidence? Mt Sinai J Med. 2009;76:330–43. 27. Judd BK, Alison JA, Waters D, Gordon CJ. Comparison of psychophysiological stress in physiotherapy students undertaking simulation and hospital-based clinical education. Simul Healthc. 2016;11(4): 271–7 https://doi.org/10.1097/SIH.0000000000000155. 28. Donlan P. Developing affective domain learning in health professions education. J Allied Health. 2018;47(4):289–95. Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.