Comparison of psychophysiological stress in physiotherapy students undertaking simulation and hospital-based clinical education

Belinda Karyn Judd, Jennifer Ailsey Alison, Donna Waters, Christopher James Gordon*

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

33 Citations (Scopus)


Introduction: Simulation-based clinical education often aims to replicate varying aspects of real clinical practice. It is unknown whether learners’ stress levels in simulation are comparable with those in clinical practice. The current study compared acute stress markers during simulation-based clinical education with that experienced in situ in a hospital-based environment.

Methods: Undergraduate physiotherapy students’ (n = 33) acute stress responses [visual analog scales of stress and anxiety, continuous heart rate (HR), and saliva cortisol] were assessed during matched patient encounters in simulation-based laboratories using standardized patients and during hospital clinical placements with real patients. Group differences in stress variables were compared using repeated measures analysis of variance for 3 time points (before, during the patient encounter, and after) at 2 settings (simulation and hospital).

Results: Visual analog scale stress and anxiety as well as HR increased significantly from baseline levels before the encounter in both settings (all P < 0.05). Stress and anxiety were significantly higher in simulation [mean (SD), 45 (22) and 44 (25) mm; P = 0.003] compared with hospital [mean (SD), 31 (21) and 26 (20) mm; P = 0.002]. The mean (SD) HR during the simulation patient encounter was 90 (16) beats per minute and was not different compared with hospital [mean (SD), 87 (15) beats per minute; P = 0.89]. Changes in salivary cortisol before and after patient encounters were not statistically different between settings [mean (SD) simulation, 1.5 (2.4) nmol/L; hospital, 2.5 (2.9) nmol/L; P = 0.70].

Conclusions: Participants’ experienced stress on clinical placements, irrespective of the clinical education setting (simulation vs. hospital). This study revealed that psychological stress and anxiety were greater during simulation compared with hospital settings; however, physiological stress responses (HR and cortisol) were comparable. These results indicate that psychological stress may be heightened in simulation, and health professional educators need to consider the impact of this on learners in simulation-based clinical education. 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.
Original languageEnglish
Pages (from-to)271-277
Number of pages7
JournalSimulation in Healthcare
Issue number4
Publication statusPublished - 2016
Externally publishedYes


  • Clinical education
  • Physiotherapy
  • Simulation
  • Stress


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