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Background  Neonatal intubation is a stressful procedure taught to trainees. This procedure can attract additional observers. The impact of observers on neonatal intubation performance by trainees has not been studied. Our objective was to evaluate if additional observers present during neonatal mannequin endotracheal intubation (NMEI) by junior trainees, affects their performance and their stress levels.    Methods  A randomized cross over trial was conducted. First year residents with no experience in neonatal intubation were assigned to NMEI condition A or B randomly on day 1. Subjects were crossed over to the other condition on day 2.  Condition A: Only one audience member was present Condition B: Presence of an audience of 5 health care providers.  Differences in the time to successful NMEI was recorded and compared between conditions. A portable heart rate monitor was used to measure peak heart rate above baseline during NMEI under both conditions.    Results  Forty nine residents were recruited. 72% were female with a median age of 25 years (IQR: 24–27). Time to successful intubation was comparable under both conditions with a mean difference of − 3.94 s (95% CI: -8.2,0.4). Peak heart rate was significantly lower under condition A (mean difference − 11.9 beats/min, 95% CI -15.98 to − 7.78).    Conclusion  Although the time required to NMEI did not increase, our results suggest that presence of observers significantly increases trainee stress. The addition of extraneous observers during simulation training may better equip residents to deal with such stressors.    Trial registration  Date of registration: March 2016,  NCT 02726724 .    Electronic supplementary material  The online version of this article (10.1186/s12909-018-1338-4) contains supplementary material, which is available to authorized users.

Effect of an audience on trainee stress and performance during simulated neonatal intubation: a randomized crossover trial