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Randomized Controlled Trial
. 2025 Sep 3;20(9):e0331488.
doi: 10.1371/journal.pone.0331488. eCollection 2025.

An adaptive simulation intervention decreases emergency physician physiologic stress while caring for patients during COVID-19: A randomized clinical trial

Leigh V Evans  1 , James W Bonz  1 , Samuel Buck  1 , Jeffrey N Gerwin  1 , Shacelles Bonner  1   2 , Suzette Ikejiani  1   3 , Tatiana Moylan  1 , Melissa Joseph  1   4   5 , Gustavo de Oliveira Almeida  6 , Jessica M Ray  7   8 , James D Dziura  1   9 , Arjun K Venkatesh  1 , Ambrose H Wong  1   2   10
Affiliations
Randomized Controlled Trial

An adaptive simulation intervention decreases emergency physician physiologic stress while caring for patients during COVID-19: A randomized clinical trial

Leigh V Evans et al. PLoS One. .

Abstract

Background: Stressful work environments and burnout in emergency medicine (EM) physicians adversely impact patient care quality. The future EM workforce will need to prioritize clinician well-being to ensure optimal patient care.

Methods: This prospective, randomized, controlled study aimed to determine whether an adaptive simulation intervention, COVID-19 Responsive Intervention: Systems Improvement Simulations (CRI:SIS), decreased physiologic stress as measured by heart rate variability (HRV) in front-line EM physicians during the COVID-19 pandemic. HRV was measured with smart shirts and self-reported State-Trait Anxiety Inventory (STAI) were collected at baseline and during four 8-hour clinical shifts for all participants. The intervention group (n = 40) received a 3-hour virtual educational simulation intervention consisting of four simulation scenarios (CRI:SIS). The control group (n = 41) received no simulation intervention.

Results: There were no significant differences in demographics between groups. HRV data collected from 81 physicians across a total of 324 clinical shifts showed an increase in HRV (decrease in physiologic stress) in shifts immediately following CRI:SIS in the intervention group as measured by a root mean square standard deviation (RMSSD) difference of 11.55 ms (95% CI, -19.90 to -3.20; P = 0.007) compared to the control group. Post-intervention STAI did not significantly differ between intervention and control.

Conclusion: An adaptive simulation-based educational intervention led to decreased physiologic stress (increased HRV) among emergency physicians who received a simulation education intervention. Reduced physiologic stress generated by adaptive simulation interventions may improve both patient safety and clinician well-being.

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Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Fig 1
Fig 1. CONSORT flow diagram depicting participant flow through the trial.
The diagram outlines the flow of participants through each stage of the randomized controlled trial, from enrollment to analysis. A total of 81 participants enrolled and completed the clinical trial. CONSORT indicates consolidated standards of reporting trials; CRI:SIS, COVID-19 Responsive Intervention: Systems Improvement Simulations.
See this image and copyright information in PMC

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