Stress level experienced by participants in realistic simulation: a systematic review

Brasil, Guilherme da Costa; Lima, Lucas Tomaz Benigno; Cunha, Elaine Carvalho; Cruz, Flávia Oliveira de Almeida Marques da; Ribeiro, Laiane Medeiros

doi:10.1590/0034-7167-2020-1151

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Sumário

REVIEW • Rev. Bras. Enferm. 74 (4) • 2021 • https://doi.org/10.1590/0034-7167-2020-1151 copy

Stress level experienced by participants in realistic simulation: a systematic review

Nivel de estrés experimentado por participantes en simulación realista: una revisión sistemática

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objectives:

to identify the available evidence regarding stress levels experienced by participants in education based on a realistic simulation.

Methods:

systematic review that included randomized clinic trials on electronic databases: Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, Latin-American and Caribbean Literature in Health Sciences, LIVIVO, PubMed, Scopus, and Web of Science. The additional search was performed on Google Scholar and OpenGrey. All searches occurred on September 24, 2020. The methodologic quality of the results was evaluated by the Cochrane Collaboration Risk of Bias Tool.

Results:

eighteen studies were included, which evaluated the participants’ stress using physiologic, self-reported measures, or the combination of both. Stress as experienced in a high level in simulated scenarios.

Conclusions:

evidence of the study included in this systematic review suggest that stress is experienced in a high level in simulated scenarios.

Descriptors:
Simulation Training; Stress, Psychological; Patient Simulation; Systematic Review; Education

Databases	Key words
PubMed	("Students"[Mesh] OR "Students, Nursing"[Mesh] OR "Nursing"[Mesh] OR "Undergraduate Nursing Students"[All Fields] OR "Physicians"[Mesh] OR "Students, Medical"[Mesh] OR "Medical Students"[All Fields] OR "Trainee"[All Fields] OR "Multidisciplinar Team"[All Fields] OR "Multidisciplinary Team"[All Fields]) AND ("Patient Simulation"[Mesh] OR "Simulation Training"[Mesh] OR "High Fidelity Simulation"[All Fields] OR "High Fidelity Simulation Training"[Mesh] OR "Education, Medical"[Mesh] OR "Education, Medical, Undergraduate"[Mesh] OR "Education, Nursing"[Mesh] OR "Post Graduate Medical Education"[All Fields] OR "High-Fidelity Manekin Education"[All Fields]) AND ("Stress, Psychological"[Mesh] OR "Stress, Physiological"[Mesh] OR "Stress Response"[All Fields] OR "Heart Rate"[Mesh] OR "Hydrocortisone"[Mesh] OR "Cortisol"[All Fields] OR "Salivary Cortisol"[All Fields])
LILACS	(tw:(estudantes OR estudiantes OR students)) AND (tw:(simulação OR simulación OR simulation))
Cochrane Library, CINAHL, LIVIVO, Scopus, Web of Science.	("Students" OR "Students, Nursing" OR "Nursing" OR "Undergraduate Nursing Students" OR "Physicians" OR "Students, Medical" OR "Medical Students" OR "Trainee" OR "Multidisciplinar Team" OR "Multidisciplinary Team") AND ("Patient Simulation" OR "Simulation Training" OR "High Fidelity Simulation" OR "High Fidelity Simulation Training" OR "Education, Medical" OR "Education, Medical, Undergraduate" OR "Education, Nursing" OR "Post Graduate Medical Education" OR "High-Fidelity Manekin Education") AND ("Stress, Psychological" OR "Stress, Physiological" OR "Stress Response" OR "Heart Rate" OR "Hydrocortisone" OR "Cortisol" OR "Salivary Cortisol")
Google Scholar, OpenGrey.	("students" AND "simulation")

Year, author, country	Groups	N	Objective of the Study	Stress Measurement	Area	Main conclusions
2018, Bensouda et al.⁽³⁰30 Bensouda B, Mandel R, Mejri A, Lachapelle J, St-Hilaire M, Ali N. Effect of an audience on trainee stress and performance during simulated neonatal intubation: a randomized crossover trial. BMC Med Educ. 2018;18(1):230. https://doi.org/10.1186/s12909-018-1338-4 https://doi.org/10.1186/s12909-018-1338-... ⁾ Canada	IG: 1 observer during simulation CG: 5 observers during simulation	IG: 24 CG: 25	Obtain evidence that interns are adversely affected by the presence of a large audience during neonatal endotracheal intubation.	Heart rate	Medicine	The presence of the external public did not negatively affect the period of the simulated intubation, but the presence of observers not belonging to the scenario was stressful.
2010, Bong et al.⁽²⁴24 Bong CL, Lightdale JR, Fredette ME, Weinstock P. Effects of simulation versus traditional tutorial-based training on physiologic stress levels among clinicians: a pilot study. Simul Healthc. 2010;5(5):272-8. https://doi.org/10.1097/SIH.0b013e3181e98b29 https://doi.org/10.1097/SIH.0b013e3181e9... ⁾ United States	IG: training based on high fidelity simulation (HFS) CG: interactive educational training session	IG: 13 CG: 14	Measure and compare physical and biochemical markers of stress in participants undergoing simulation with those undergoing teaching sessions/tutorials.	Salivary cortisol, heart rate	Medicine and Nursing	Regardless of the role of participants in the simulation, all showed high levels of physiological stress.
2018, Boostel et al.⁽³⁴34 Boostel R, Felix JVC, Bortolato-Major C, Pedrolo E, Vayego SA, Mantovani MF. Stress of nursing students in clinical simulation: a randomized clinical trial. Rev Bras Enferm. 2018;71(3):967-74. https://doi.org/10.1590/0034-7167-2017-0187 https://doi.org/10.1590/0034-7167-2017-0... ⁾ Brazil	IG: class followed by simulation CG: class followed by laboratory practice	IG: 27 CG: 25	Evaluate the perception of students' stressors before and after the clinical simulation or the conventional practical class in the laboratory.	Questionary	Nursing	The simulation increased the perception of stressors related to the lack of competence and the interpersonal relationship when acting in front of the patient, multidisciplinary team, and colleagues compared to the conventional practical class in the laboratory.
2016, Demaria et al.⁽³⁵35 DeMaria S, Silverman ER, Lapidus KA, Williams CH, Spivack J, Levine A, et al. The impact of simulated patient death on medical students' stress response and learning of ACLS. Med Teach. 2016;38(7):730-7. https://doi.org/10.3109/0142159X.2016.1150986 https://doi.org/10.3109/0142159X.2016.11... ⁾ United States	IG: simulation group with death CG: simulation group with survival	IG: 13 CG: 14	Describe the physiological and biochemical stress response in students during the simulation of a patient death compared to a group whose patient is programmed to survive.	Salivary cortisol, DHEA hormone and heart rate	Medicine	Students experienced stress during high fidelity simulation; there was not a negative response of a scenario with death compared to a survival scenario.
2012, Finan et al.⁽³⁶36 Finan E, Bismilla Z, Whyte HE, Leblanc V, McNamara PJ. High-fidelity simulator technology may not be superior to traditional low-fidelity equipment for neonatal resuscitation training. J Perinatol. 2012;32(4):287-92. https://doi.org/10.1038/jp.2011.96 https://doi.org/10.1038/jp.2011.96... ⁾ Canada	IG: HFS simulation CG: low fidelity simulation (LFS)	IG: 8 CG: 8	Compare the effects of HFS versus LFS on stress measurements in a group of neonatology interns.	Survey and salivary cortisol	Medicine	The use of HFS and LFS technology increased subjective and objective stress measures. HFS did not offer additional benefits in terms of stress modification.
2015, Flinn et al.⁽³⁷37 Flinn JT, Miller A, Pyatka N, Brewer J, Schneider T, Cao CG. The effect of stress on learning in surgical skill acquisition. Med Teach. 2016;38(9):897-903. https://doi.org/10.3109/0142159X.2015.1114597 https://doi.org/10.3109/0142159X.2015.11... ⁾ United States	CG: control group OG: observed group EG: encouraged group CGi: criticized group	CG: 10 OG: 10 EG: 10 CGi: 10	Compare the effects of the LFS simulator versus HFS technology on performance levels, objective and subjective measures of stress in neonatology interns.	MBP, heart rate, skin conductance, basal cortisol and Anxiety Inventory	Medicine	The criticized group had higher levels of stress compared to the control group. The presence of an expert evaluator produced higher levels of stress for participants.
2019, Ghazali et al.⁽²⁹29 Ghazali DA, Breque C, Sosner P, Lesbordes M, Chavagnat JJ, Ragot S, et al. Stress response in the daily lives of simulation repeaters. A randomized controlled trial assessing stress evolution over one year of repetitive immersive simulations. PLoS One. 2019;14(7):e0220111. https://doi.org/10.1371/journal.pone.0220111 https://doi.org/10.1371/journal.pone.022... ⁾ France	IG: 9 simulations for 1 year CG: 3 simulations for 1 year	IG: 24 CG: 24	Analyze physiological stress according to the frequency of repetition of simulations.	Heart rate variability	Medicine, nursing, paramedic, ambulance driver	Stress is recurrent in repeated high-fidelity simulation sessions in life-threatening events and decreases over 24 hours.
2009, Girzadas et al.⁽³³33 Girzadas DV Jr, Delis S, Bose S, Hall J, Rzechula K, Kulstad EB. Measures of stress and learning seem to be equally affected among all roles in a simulation scenario. Simul Healthc. 2009 Fall;4(3):149-54. https://doi.org/10.1097/SIH.0b013e3181abe9f2 https://doi.org/10.1097/SIH.0b013e3181ab... ⁾ United States	IG: team leader in simulation CG: member in simulation	38	Measure heart rates and stress and learning perceived by participants in two simulation scenarios, in addition to evaluating their responses to questions at the end of the experiment.	Heart rate, survey	Students and medical residents	The participants' heart rate increased from the pre-procedure to the critical intervention. Self-reported learning values increased with self-reported stress levels.
2020, Hardenberg, Rana, Tori⁽¹1 Hardenberg J, Rana I, Tori K. Evaluating impact of repeated exposure to high fidelity simulation: skills acquisition and stress levels in postgraduate critical care nursing students. Clin Simul Nurs. 2020;48:96-102. https://doi.org/10.1016/j.ecns.2020.06.002 https://doi.org/10.1016/j.ecns.2020.06.0... ⁾ Australia	IG: repeated simulation sessions CG: a single simulation session	IG: 7 CG: 7	Investigate whether repeated exposure to a challenging clinical scenario leads to a reduction in stress levels.	Heart rate	Nursing	Repeated simulation exposure did not reduce stress levels measured by heart rate.
2013, Hunziker et al.⁽³⁸38 Hunziker S, Pagani S, Fasler K, Tschan F, Semmer NK, Marsch S. Impact of a stress coping strategy on perceived stress levels and performance during a simulated cardiopulmonary resuscitation: a randomized controlled trial. BMC Emerg Med. 2013;13:8. https://doi.org/10.1186/1471-227X-13-8 https://doi.org/10.1186/1471-227X-13-8... ⁾ Switzerland	IG: with previous instructions on how to deal with stress CG: no previous instructions on how to deal with stress	IG: 62 CG: 62	Describe stress patterns during a simulation and investigate perceived stress and its association with coping and performance strategy.	Survey	Medicine	A brief stress coping strategy moderately decreased perceived stress without significantly affecting performance in a CPR scenario.
2015, Ignacio et al.⁽⁴¹41 Ignacio J, Dolmans D, Scherpbier A, Rethans JJ, Chan S, Liaw SY. Comparison of standardized patients with high-fidelity simulators for managing stress and improving performance in clinical deterioration: a mixed methods study. Nurse Educ Today. 2015;35(12):1161-8. https://doi.org/10.1016/j.nedt.2015.05.009 https://doi.org/10.1016/j.nedt.2015.05.0... ⁾Singapore	IG: use of standardized patient in the simulation CG: use of mannequin in the simulation	IG: 29 CG: 28	Compare the effects of using a standardized patient and high-fidelity mannequin on students' stress levels and performance.	Salivary alpha-amylase and focus group	Nursing	Performance and stress during training did not differ with or without a standardized patient. However, in the focus group, we noticed that using standardized patients in the simulation had advantages over the mannequin.
2017, Lizotte et al.⁽²⁷27 Lizotte MH, Janvier A, Latraverse V, Lachance C, Walker CD, Barrington KJ, et al. The impact of neonatal simulations on trainees' stress and performance: a parallel-group randomized trial. Pediatr Crit Care Med. 2017;18(5):434-41. https://doi.org/10.1097/PCC.0000000000001119 https://doi.org/10.1097/PCC.000000000000... ⁾ Canada	IG: simulation with death CG: simulation with survival	IG: 21 CG: 21	Evaluate the impact of simulations on stress and performance both during a simulation with survivors and in simulated death.	Survey, salivary cortisol	Medicine	The simulation caused stress without interfering with performance. Having a "dead" mannequin during the simulation did not increase objective stress or interfere with performance.
2013, Meunier et al.⁽²⁸28 Meunier J, Merckaert I, Libert Y, Delvaux N, Etienne AM, Liénard A, et al. The effect of communication skills training on residents' physiological arousal in a breaking bad news simulated task. Patient Educ Couns. 2013;93(1):40-7. https://doi.org/10.1016/j.pec.2013.04.020 https://doi.org/10.1016/j.pec.2013.04.02... ⁾ Belgium	IG: with previous training on communication CG: no previous training on communication	IG: 50 CG: 48	Evaluate the effect of communication training on physiological arousal during an adverse communication simulation.	Heart rate, salivary cortisol and survey	Medicine	Communication skills training affects physiological arousal in a simulated adverse communication task.
2013, Pottier et al.⁽³⁹⁾ France	IG: high stress scenario CG: low stress scenario	IG: 21 CG:20	Assess the impact of subjective and physiological stress on student decision-making and communication skills in an outpatient setting.	Scales, cognitive evaluation, Anxiety Inventory, salivary cortisol	Medicine	The simulated high-stress outpatient consultation is a negative impact situation for students, leading to failures in clinical reasoning and diagnostic errors.
2010, Prabhu et al.⁽⁴⁰40 Prabhu A, Smith W, Yurko Y, Acker C, Stefanidis D. Increased stress levels may explain the incomplete transfer of simulator-acquired skill to the operating room. Surgery. 2010;147(5):640-5. https://doi.org/10.1016/j.surg.2010.01.007 https://doi.org/10.1016/j.surg.2010.01.0... ⁾ United States	IG: previous suture training CG: no previous suture training	IG: 13 CG: 07	Examine the trainees' stress level during the transition from the simulator to the operating room and its impact on performance.	Survey, heart rate, and heart rate variability	Medicine	The improper transition from the simulator to the operating room involving the acquired skills may be a consequence of increased stress and anxiety. Heart rate was a better measure of stress compared to heart rate variability.
2017, Sorensen et al.⁽³²32 Sorensen JL, van der Vleuten C, Rosthoj S, Ostergaard D, LeBlanc V, Johansen M, et al. Simulation-based multiprofessional obstetric anaesthesia training conducted in situ versus off-site leads to similar individual and team outcomes: a randomised educational trial. BMJ Open. 2015;5(10):e008344. https://doi.org/10.1136/bmjopen-2015-008344 https://doi.org/10.1136/bmjopen-2015-008... ⁾ Denmark	IG: in situ simulation CG: clinic simulation	IG: 48 CG: 49	Investigate the effect of simulation in situ versus clinical simulation on knowledge, safety, stress, motivation, perception of simulation, team performance, and organizational impact among multidisciplinary teams of obstetric anesthesia.	Survey, salivary cortisol	Medicine and nursing	There was no finding that education based on simulation conducted in situ compared to clinical simulation led to different results evaluated in stress.
2018, Timberlake, Stefanidis and Gardner⁽⁴²42 Timberlake MD, Stefanidis D, Gardner AK. Examining the impact of surgical coaching on trainee physiologic response and basic skill acquisition. Surg Endosc. 2018;32(10):4183-90. https://doi.org/10.1007/s00464-018-6163-7 https://doi.org/10.1007/s00464-018-6163-... ⁾ United States	IG: laparoscopic suture training with video and instructor practice CG: laparoscopic suture training with video and practice without an instructor	IG: 12 CG: 12	Examine the impact of a specific teaching technique on skill acquisition and physiological stress.	Heart rate, heart rate variability, respiratory rate	Medicine	Students who receive surgical training exhibit greater performance gains compared to those who do it self-directed. Improvements in skill acquisition correlated with increases in heart rate variability.
2016, Waterland et al.⁽³¹31 Waterland P, Khan FS, Ismaili E, Cheruvu C. Environmental noise as an operative stressor during simulated laparoscopic surgery. Surg Laparosc Endosc Percutan Tech. 2016;26(2):133-6. https://doi.org/10.1097/SLE.0000000000000250 https://doi.org/10.1097/SLE.000000000000... ⁾ England	IG: simulation with 80 dB noises. CG: simulation in silence	IG: 35 CG: 35	Determine the effect of environmental noise on the psychological and physiological response to stress in students during simulated laparoscopic surgery.	Anxiety Inventory, heart rate	Medicine	Environmental noises generated an increase in the participants' stress response in simulated laparoscopic surgery environments.

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[1] Corresponding author: Guilherme da Costa Brasil E-mail: guilhermecostabrasil@hotmail.com