Psychophysiological fidelity: A comparative study of stress responses to real and simulated clinical emergencies

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Introduction: Experiencing psychological stress may affect clinician performance in acute emergencies. While simulation is used extensively in healthcare education, it is unknown whether simulation effectively replicates the psychophysiological stress of real-world conditions. Thus, this study explored whether measurable differences exist in psychophysiological responses to acute stress in simulated compared with real-world clinical practice. Methods: In this within-subjects observational study, stress appraisals, state anxiety and heart rate variability (HRV) were recorded during simulated and real-world emergencies in a 6-month training placement in neonatal medicine. Eleven postgraduate trainees and one advanced neonatal nurse practitioner participated. Mean (SD) participant age was 33 (8) years; and eight participants (67%) were female. Data were collected at rest and immediately before, during and 20 min after simulated and real-world neonatal emergencies. In situ simulation scenarios were modelled on those used in accredited neonatal basic life support training. Stress appraisals and state anxiety were assessed using Demand Resource Evaluation Scores and the short State-Trait Anxiety Inventory, respectively. High-frequency power, a component of HRV associated with parasympathetic tone, was derived from electrocardiogram recordings. Results: Simulation was associated with greater likelihood of threat appraisal and higher state anxiety. High-frequency HRV reduced from baseline in simulated and real-world emergencies but recovered further towards baseline 20 min after simulated events. Possible explanations for the observed differences between conditions include participants' previous experiences and expectations of simulation and the effect of post-simulation debrief and feedback. Discussion: This study identifies important differences in psychophysiological stress responses to simulated and real-world emergencies. Threat appraisals, state anxiety and parasympathetic withdrawal are educationally and clinically significant, given their known associations with performance, social functioning and health regulation. While simulation may facilitate interventions aimed at optimising clinicians' stress responses, it is vital to confirm that outcomes transfer to real-world clinical practice.

Original languageEnglish
Pages (from-to)1248-1256
Number of pages9
JournalMedical Education
Issue number12
Early online date1 Jul 2023
Publication statusPublished - 31 Dec 2023

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.


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