Table 1 Articles eligible for inclusion

Baker BG, Bhalla A, Doleman B, Yarnold E, Simons S, Lund JN, Williams JP. 2017

United Kingdom

Aimed to compare the stress induced by simulation with clinical environments. Eight anaesthetic trainees in their first 3 years of study.

Objective (heart rate variability (HRV)) and subjective (state trait anxiety inventory (STAI) measures of stress recorded and compared.

Simulation was unable to accurately replicate the stress of the technical procedure performed in theatre. Simulation may induce a level of pre-performance anxiety.

Evaluate participant stress in different simulated environments to assess triggers as a learning tool. Optimize simulation for assessment and stress management training.

Barbadoro P, Brunzini A, Dolcini J, Formenti L, Luciani A, Messi D, Papetti A, Ponzio E, Germani M, Adrario E. 2023.

Italy

Aimed to compare stress responses during high-fidelity (HF) and procedural simulation (PS) for 148 medical students.

Compared self-perceived and biological level (salivary cortisol variations) stress responses for two simulation methods.

Both the psychological and the biological stress levels increased due to simply being in a simulation scenario; opposed to the intrinsic complexity of tasks being performed.

More studies are needed to confirm this trend and to clarify the role of simulated stress response in a long- term learning.

Beltrán-Velasco AI, Bellido-Esteban A, Ruisoto-Palomera P, Clemente-Suárez VJ. 2018.

Spain

Aimed to explore changes in the autonomic stress response of 14 psychology students during a stressful OSCE.

Analysis of HRV in temporal, frequency and non-linear domains, subjective perception of distress strait and academic performance were measured before and after the two different OSCEs.

Produced a large anxiety anticipatory response, a habituation response; autonomic modulation parameters did not correlate with academic performance of these students.

Instruments to measure HRV in real time during OSCE useful increase students’ performance; help students control stress response using biofeedback; help teachers improve simulation experience.

Beltrán-Velasco AI, Ruisoto-Palomera P, Bellido-Esteban A, García-Mateos M, Clemente-Suárez VJ. 2019.

Spain

Aimed to study psychophysiological responses of 15 physiotherapy students during clinical practice and assess their coping style relevant to impact on academic performance.

Analysis of HRV along with six different psychological measurements questionnaires across 11 evaluation points of a three-month clinical placement.

None of the psychophysiological variables analysed were related to academic performance. No habituation / no increased parasympathetic response.

Extending this study to other educational levels could provide valuable information on the stressful events faced and strategies used.

Bialka S, Copik M, Ubych A, Marciniak R, Smereka J, Szarpak L, Misiolek H. 2021.

Poland

Prospective, observational study evaluating the degree of stress in 55 final year medical students during critical care classes.

Before and after scenario, systolic blood pressure (BP), diastolic BP, mean BP, Heart Rate (HR), blood oxygen saturation and saliva stress hormone levels assessed.

BP and HR significantly higher after scenario. Stress hormones remained elevated after scenario for two hours.

High-fidelity simulation induces stress comparable with clinical duties, but it can also lead to underperformance if the stress is too high.

Demaria S, Jr., Bryson EO, Mooney TJ, Silverstein JH, Reich DL, Bodian C, Levine AI. 2010.

United States of America

Aimed to determine if added emotional stress increased anxiety during cardiopulmonary arrest scenario for 25 medical students early in their studies.

Randomised control trial (RCT) with actors scripted to add stress (ES). HR and subjective stress recorded before and after with follow up at six months later.

ES group experienced increased physiological responses and greater anxiety. Six months later, written test scores similar, but ES group participants achieved higher practical competency.

Limited data regarding the effects of stress on educational outcomes in the medical simulation literature. This investigation suggests that there are levels of anxiety that enhance learning.

DeMaria S, Silverman ER, Lapidus KAB, Williams CH, Spivack J, Levine A, Goldberg A. 2016

United States of America

Aimed to describe the physiologic and biochemical stress response induced by simulated patient death for 26 medical students early in their studies.

High-fidelity simulation (HFS) used with participants randomized to simulated death or survival. HR and salivary stress hormone levels assessed.

Learners experience stress during HFS; however, no detectable difference or negative response to a simulated patient death compared with simulated survival.

Notion that concerns over deliberately permitting the simulated patient to die may be overestimated, authors found no apparent psychological harm

Feeley AA, Feeley IH, McManus R, Lunn JV, Sheehan E, Merghani K. 2022.

Ireland

Aimed to evaluate the cumulative impact of supervision on technical skills and surrogate stress markers in 20 orthopaedic surgical trainees at a Tertiary trauma centre.

Quasi-experimental crossover study evaluating impact of attending supervision on trainee stress response (HRV) during a simulated surgical procedure.

Presence of supervision during simulated surgical performance increased stress response compared to unsupervised task and baseline measurements.

Accretion of technical and non-technical skills may benefit from the use of simulation-based training in surgical residents in both supervised and unsupervised sessions.

Flinn JT, Miller A, Pyatka N, Brewer J, Schneider T, Cao CGL. 2016.

United States of America

To characterize the effects of stress resulting from attending–trainee interaction during surgical skill acquisition for 40 medical students.

RCT – participants observed, encouraged, or criticized by an expert. BP, HR, skin conductance, salivary cortisol, task performance and subjective stress assessed.

Participants who were criticized performed the worst and those who were encouraged performed best. Physiological and subjective measures showed criticized participants experienced the highest level of stress and anxiety.

Teacher–student interaction should not be negatively critical to the point of being appraised as threat-like in nature. Future research investigating the threshold for threat in stress appraisals to allow for more effective teacher-student interactions.

Harvey A, Nathens AB, Bandiera G, LeBlanc VR. 2010.

Canada

Determine extent to which cognitive appraisal affects 13 medical trainee’s physiological and subjective stress responses to high-acuity simulated clinical situations.

RCT - high (HS) and low (LS) stress trauma resuscitation simulations. Subjective and physiological (salivary cortisol) measures compared.

Post-scenario, subjective stress scores, cognitive appraisal and cortisol levels were higher in the HS scenario compared with the LS scenario.

Subjective appraisals of a situation as a threat impairs performance. As such, training for high-acuity events should include interventions targeting stress management skills.

Judd BK, Alison JA, Waters D, Gordon CJ. 2016.

Australia

Aimed to compare acute stress during simulation-based clinical education with that experienced in situ in a hospital- based environment for 33 undergraduate physiotherapy students.

Subjective stress responses, anxiety, continuous HR, and saliva cortisol assessed in simulation using standardized patients and during hospital clinical placements with real patients.

Stress and anxiety were significantly higher in simulation compared with hospital. Physiological stress responses (HR and cortisol) were comparable.

New learners in their clinical education program may benefit from a less stressful simulation environment before a gradual increase in stress demands as they approach clinical practice.

Keitel A, Ringleb M, Schwartges I, Weik U, Picker O, Stockhorst U, Deinzer R. 2011.

Germany

To assess psychological and endocrine stress responses for 34 medical students and relationship between stress reactivity and medical performance in simulation

A counterbalanced cross-over design of three situations. Salivary cortisol, psychological responses medical performance were assessed.

Cortisol increased significantly in both stress conditions and surprisingly correlated significantly with improved medical performance.

Future studies should analyse the educational implications of the massive stress response observed under simulation and if this actually improves clinical performance.

Los, K, Chmielewski J, Cebula G, Bielecki T, Torres K, Luczynski, W. 2021.

Poland

Aimed to determine whether the technical and non-technical skills of medical students undertaking 166 paediatric high-fidelity simulations are related mindfulness and stress.

Standardized simulations were conducted assessing: stress sensation (subjectively and HR / BP) technical and non-technical skills and mindfulness.

Mindfulness of students is associated with non-technical skill i.e., avoiding fixation error. However, did not correlate with alterations in HR and pressure before and after a simulation.

Mindfulness courses included in the medical university curriculum and early career of a young doctor to reduce stress and improve the diagnostic and therapeutic effectiveness of physicians.

MacQuarrie AS, Hunter JR, Sheridan S, Hlushak A, Sutton C, Wickham J. 2022.

Australia

To assess if the clinical performance of 11 paramedicine students and graduates is affected by fatigue, compared with performing the scenario without prior activity.

Randomized crossover design of high-fidelity simulations after either acute physical activity or rest. HR, respiratory rate (RR), BP, and clinical performance assessed.

Participants performed as well, or better, immediately after acute physical activity compared with rest, despite higher physiological exertion.

This pilot study shows physical activity did not result in clinical performance decrements and should be the catalyst for further research in this area.

Martín-Rodríguez F, Castro Villamor MA, López-Izquierdo R, Portillo Rubiales RM, Ortega GJ, Sanz-García A. 2021

Spain

Aimed develop a predictive model (demographic, physiologic, and metabolic) capable of determining which final year medical students (n = 163) present high anxiety levels.

Randomized, sham-controlled, blinded trial assessing HR, BP, salivary pH, lactate and subjective stress questionaries before and after simulations.

Predictive demonstrated age and systolic blood pressure found to be protective factors against anxiety. The type of scenario or the role played had no effect on anxiety.

Early identification of which students will have high levels of anxiety could allow the introduction of avoidance measures and improve learning during the medical simulation.

McKay KAC, Buen JE, Bohan KJ, Maye JP. 2010.

United States of America

Prospective descriptive design to compare baseline, acute, and recovery measurements of stress with performance scores of 18 student nurse anaesthetists.

Students simulated induction and intubation sequence. HR, BP sweat levels, salivary α-amylase and subjective stress levels assessed before and after.

Low performers increased stress and performed poorly, high performers increased stress and performed superbly, and moderate performers had modest stress and performed moderately.

Obtaining more knowledge related to the impact of acute stress on performance can only benefit and improve educational programs and lead to the development of strategies to help students succeed.

Nakayama N, Arakawa N, Ejiri H, Matsuda R, Makino T. 2018.

Japan

This study sought to clarify stress changes throughout the progression of different phases of a simulation for 74 nursing students.

HRV and subjective responses recorded across 4 phases of simulation - the break, patient care, reporting, and debriefing.

The reporting phase involved high objective and subjective stress. The debriefing phase did not significantly differ from the break phase for objective or subjective stress.

It may be possible that the educator’s evaluative attitude increased students’ stress. Therefore, a stress intervention during the reporting phase might further improve student performance during that phase.

Palekar TJ, Mokashi MG, Anwer S, Kakrani AL, Khandare SD, Alghadir AH. 2015

Saudi Arabia

Aimed to assess if galvanic skin resistance-aided biofeedback (GSRBF) could reduce stress in 43 physiotherapy students.

A pretest-posttest quasi-experimental study assessing stress metrics (HR, RR, BP, and perceived stress) following GSRBF training.

GSRBF training was found to produce a significant reduction in the physiological response and perceived stress in physiotherapy students.

Further, controlled research should be conducted to verify these findings and to identify if long term GSRBF is an effective stress reducing training protocol.

Park HJ, Choi D, Park HA, Lee CA. 2022.

Republic of Korea

Aims to evaluate 132 nursing students’ stress levels during CPR simulation training and to determine the correlation between individual personality traits and stress levels.

Prospective observational study measuring HRV via a smartwatch and any correlation between personality and stress.

A weak negative correlation was observed between the agreeableness personality trait and stress measurements.

More effective training can be developed when individual perception, opinions, and experiences are considered within individuals’ acceptable stress levels.

Rieber N, Betz L, Enck P, Muth E, Nikendei C, Schrauth M, Werner A, Kowalski A, Zipfel S. 2009.

Germany

The purpose of this study was to quantitatively evaluate stress and motivation in both students and standardised patients (SPs) during scenarios (n = 44 medical students)

Stress and motivation in both students and SPs during scenarios. HRV measured continuously; motivation questionnaire before scenario.

HRV lower in both students and SPs during the scenarios. Motivation increased for scenario involving psychosomatic illness but decreased for somatic.

Future studies to consider subjective tension and motivation prior to and after scenario to elucidate individual contributions made by knowledge, motivation and stress.

Stecz P, Makara-Studzińska M, Białka S, Misiołek H. 2021.

Poland

Study aimed to assess stress parameters of 56 undergraduate anaesthesiology students

Prospective observational study assessing psychological (anxiety and stress state), physiological (HR, BP), immunological, and humoral levels of stress during high-fidelity simulation training.

No clear relationships were found between biological stress and trait anxiety. Stress markers varied depending on the assigned roles; however, the trajectories of responses were similar.

Medical students were generally resistant to acute stress. Best practice should involve management of students’ wellbeing, i.e., emotional distress reduction after simulation or switching the assigned roles.

Tramèr L, Becker C, Hochstrasser S, Marsch S, Hunziker S. 2018.

Switzerland

Study aimed to analyse electrocardiogram (ECG) alterations in 126 medical student rescuers and its association with gender and CPR performance.

Prospective, observational simulator study using ECG output before, during and after CPR. HR, HRV, and ST- and T-wave morphology analysed.

HR increased significantly during resuscitation, from values before resuscitation and decreased after resuscitation. T-wave and ST-segment abnormalities observed in approx. 30% of participants.

Cardiopulmonary resuscitation caused significant ECG alterations in healthy medical students with ST-segment and T-wave abnormalities, with more pronounced effects in females.