Association between cortisol levels and performance in clinical simulation: a systematic review

Teixeira, Jackson Gois; Lima, Lucas Tomaz Benigno; Cunha, Elaine Carvalho; Marques da Cruz, Flavia Oliveira de Almeida; Carneiro, Karen Karoline Gouveia; Ribeiro, Laiane Medeiros; Brasil, Guilherme da Costa

doi:10.1590/1980-220X-REEUSP-2023-0279en

Jackson Gois Teixeira

Centro Universitário do Distrito Federal, Departamento de Enfermagem, Brasília, DF, Brazil.

https://orcid.org/0000-0003-2804-1130

Lucas Tomaz Benigno Lima

Universidade de Brasília, Programa de Pós-Graduação em Enfermagem, Brasília, DF, Brazil.

https://orcid.org/0000-0001-7839-0115

Elaine Carvalho Cunha

Centro Universitário do Distrito Federal, Departamento de Enfermagem, Brasília, DF, Brazil.

https://orcid.org/0000-0003-3477-1885

Flavia Oliveira de Almeida Marques da Cruz

Centro Universitário do Distrito Federal, Departamento de Enfermagem, Brasília, DF, Brazil.

https://orcid.org/0000-0002-6476-5972

Karen Karoline Gouveia Carneiro

Centro Universitário do Planalto Central Apparecido dos Santos, Departamento de Enfermagem, Brasília, DF, Brazil.

https://orcid.org/0000-0001-8614-2285

Laiane Medeiros Ribeiro

Universidade de Brasília, Departamento de Enfermagem, Brasília, DF, Brazil.

https://orcid.org/0000-0002-5041-8283

Guilherme da Costa Brasil

Centro Universitário do Distrito Federal, Departamento de Enfermagem, Brasília, DF, Brazil.

https://orcid.org/0000-0001-6878-7098

Corresponding author: Jackson Gois Teixeira, Mc 01, Lot 43, Império dos Nobres Condomínio, 73252-105 – Sobradinho, DF, Brazil, jacksonudf1@gmail.com

ASSOCIATE EDITOR

Cristina Lavareda Baixinho

Database	Keywords
PubMed	#1 = (“Patient Simulation”[MeSH] OR “Simulation Training”[MeSH] OR “Simulation Training/methods”[MeSH]) OR “High Fidelity Simulation”[All Fields] OR “High Fidelity Simulation Training”[Mesh]) #2 = (“Stress, Psychological”[MeSH] OR “Stress, Physiological”[MeSH] OR “Stress Response”[All Fields] OR “Hydrocortisone”[MeSH] OR Cortisol[All Fields] OR “Salivary Cortisol”[All Fields] OR “Saliva/chemistry”[MeSH]) #3 = #1 AND #2
LILACS	(“Patient Simulation” OR “Simulation Training”) AND (“stress, psychological” OR “salivary cortisol”)
ĹIVIVO	(“Patient Simulation” OR “Simulation Training” OR “High Fidelity Simulation” OR “High Fidelity Simulation Training” OR “High-Fidelity Manikin” OR Simulation) AND (“Stress, Psychological” OR “Stress, Physiological” OR “Stress Response” OR “Hydrocortisone” OR Cortisol OR “Salivary Cortisol”)
SCOPUS	(ALL (“Patient Simulation” OR “Simulation Training” OR “High Fidelity Simulation” OR “High Fidelity Simulation Training” OR “High-Fidelity Manikin” OR simulation) AND TITLE-ABS-KEY (cortisol OR “Salivary Cortisol”) )
Web of Science	TS=((“Patient Simulation” OR “Simulation Training” OR “High Fidelity Simulation” OR “High Fidelity Simulation Training” OR “High-Fidelity Manikin” OR Simulation) AND TS=(“Stress, Psychological” OR “Stress, Physiological” OR “Stress Response” OR “Hydrocortisone” OR Cortisol OR “Salivary Cortisol”)
EMBASE	#1 = (“patient simulation”/exp OR “patient simulator”/exp OR “simulation training”/exp OR “high fidelity simulation training”/exp OR “high fidelity simulation”) #2 = (“psychological stress”/exp OR “Stress, Physiological” OR ‘mental stress’/exp “Stress Response” OR hydrocortisone/exp OR cortisol OR “salivary cortisol”) #3 = #1 AND #2
Google Scholar	(“Patient Simulation” OR “ Simulation Training” OR simulation) AND (“psychological stress” OR “cortisol”) Where my words occur: anywhere in the article 100 most relevant hits (10 pages)
Proquest	(“Patient Simulation” OR “Simulation Training” OR “Simulation Training/methods” OR “High Fidelity Simulation” OR “High Fidelity Simulation Training”) AND (“Stress, Psychological” OR “Stress, Physiological” OR “Stress Response” OR “Hydrocortisone” OR Cortisol OR “Salivary Cortisol” OR “Saliva/chemistry”)

Year, author, country	Groups	N	Study characteristics / objective	Cortisol measurements	Cortisol	Performance	Area	Main conclusions
2017, Lizotte et al., Canada(²²22. 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. http://doi.org/10.1097/PCC.0000000000001119. PubMed PMID: 28282325. https://doi.org/10.1097/PCC.000000000000... ).	IG: Simulation with death.	IG: 21	Evaluate the impact of simulations on trainees’ stress and performance; both during a “traditional” simulation (mannequin-survivors) and during a simulated death.	Salivary Cortisol.	T0: 0,10 µg/dL [IQR 0,07–0,14]. T1: 0,11 µg/dL [IQR 0,10–0,17]. T2: 0,17 µg/dL [IQR 0,13–0,28].	First scenario: 82 [IQR 78–88] = 0.85. Second scenario: 79 [IQR 77–86] = 0.87.	Medicine.	Neonatal simulation causes stress before and during the simulation without interfering with performance. Having a “dead” mannequin during a simulation does not increase objective stress or interfere with performance.
	CG: Simulation with survival	CG:21	T0: 0,10 µg/dL [IQR 0,06–0,15]. T1:0,15 µg/dL [IQR 0,09–0,22]. T2:0,23 µg/dL [IQR 0,14–0,47].	Salivary Cortisol.	First scenario: 83 [IQR 74–89] = 0.85. Second scenario: 82 [IQR 72–88] = 0.87.		Medicine.

2011, Keitel et al., Germany(⁹9. Keitel A, Ringleb M, Schwartges I, Weik U, Picker O, Stockhorst U, et al. Endocrine and psychological stress responses in a simulated emergency situation. Psychoneuroendocrinology. 2011;36(1):98–108. doi: http://doi.org/10.1016/j.psyneuen.2010.06.011.PubMed PMID: 20650570. https://doi.org/10.1016/j.psyneuen.2010.... ).	IG: Simulated emergency situation.	34	To evaluate the psychological and endocrine responses to stress in realistic simulation and the relationship between performance and stress.	Salivary Cortisol.	–15 min: 0.25µg/dL (–0,25–0,75 IC). 0 min: 0.22 µg/dL (–0.27–0.72 IC). 15 min: 0.26 µg/dL (–0,24–0.76 IC). 30 min: 0.11 µg/dL (–0.39–0.61). 45 min: –0.15 µg/dL (–0.65–0.35 IC). 60 min: –0.25 µg/dL (–0.75–0.25 IC). 75 min: –0.10 µg/dL (–0.60–0.40 IC).	No significant correlation between increased salivary cortisol and performance (p = 0.811 and p = 0.631).	Medicine.	The positive relationship between endocrine stress response in a standard laboratory situation and performance in a simulated emergency situation indicates that high stress responsiveness can be a predictor of good performance.
	CG: Resting Condition.	34		Salivary Cortisol.		correlated significantly with the increase in cortisol (p = 0.019).	Medicine.

2016, Demaria et al., United States(²³23. 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. doi: http://doi.org/10.3109/0142159X.2016.1150986. PubMed PMID: 27052665. https://doi.org/10.3109/0142159X.2016.11... ).	IG: Simulation with death.	IG: 13	Describe the physiological and biochemical stress response between simulation with death and simulation with survival.	Salivary Cortisol.	0,193 µg/dL. The average increase in SC was 0.053 µg/dL [0.071 to 0.165].	83,3% [75–85,8] = (p = 0,18).	Medicine.	There was no negative response to a simulated patient death compared to simulated survival. Salivary cortisol increased compared to baseline levels, but there were no significant differences.
	CG: Simulation with survival.	CG: 13		Salivary Cortisol.	0,159 µg/dL. 0,056 µg/dL [0,033–0,163] no statistical significant difference between groups	75% [64,1–84,2].	Medicine.

2014, Piquette et al., Canadá(²⁴24. Piquette D, Tarshis J, Sinuff T, Fowler RA, Pinto R, Leblanc VR. Impact of acute stress on resident performance during simulated resuscitation episodes: a prospective randomized cross-over study. Teach Learn Med. 2014;26(1):9–16. doi: http://doi.org/10.1080/10401334.2014.859932. PubMed PMID: 24405341. https://doi.org/10.1080/10401334.2014.85... ).	IG: Simulation with high stress scenario.	IG: 26	To explore the effects of modifiable external stressors on the simulated clinical performance of residents.	Salivary Cortisol.	Pre scenario (–15 min): 7.65 ± 5.19. Pre scenario (–5 min): 9.07 ± 6.39. Post scenario (0 min): 9.25 ± 7.17. Post scenario (10 min): 9.71 ± 7.00. Post scenario (20 min): 8.33 ± 5.08.	4.7 ± 0.9. 72% ± 11%.	Medicine.	There were significant physiological and psychological stress responses in the residents when they went through simulated resuscitation scenarios. Cortisol levels showed better performance in group A.
	CG: Simulation with low-stress scenario.	CG: 28		Salivary Cortisol.	Pre scenario (–15 min): 7.11 ± 4.50. Pre scenario (–5 min): 8.14 ± 5.11. Post scenario (0 min): 8.64 ± 6.10. Post scenario (10 min): 9.20 ± 6.67. Post scenario (20 min): 7.70 ± 5.69.	4.9 ± 0.8. 70% ± 11%.	Medicine.

2013, Meunier et al., Belgium(²⁵25. 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;913(1):40–7. doi: http://doi.org/10.1016/j.pec.2013.04.020. PubMed PMID: 23726746. https://doi.org/10.1016/j.pec.2013.04.02... ).	IG: trained residents.	IG: 50	To evaluate the effect of communication skills training on residents’ physiological arousal during the communication of bad news.	Salivary cortisol	Rest until end of preparation (before 32.4 ± 22.0 / after 44.9 ± 28.0). End of preparation to end of simulation (before 130.5 ± 81.7 / after 166.5 ± 100.8). End of simulation until 10 min recovery: (before 64.4 ± 47.5 / after 75.3 ± 47.1). Recovery from 10 min to 30 min: (before 105.8 ± 73.2 / after 131.3 ± 77.5). Rest until 30 min recovery: (before 346.0 ± 219.0 / after 441.3 ± 247.6).	Objective performance: open and directed questions (before 3.2±2.0 / after 5.2 ± 3.5). Support: recognition and empathy (before 23.3 ± 14.4 / after 27.1 ± 15.2). Information: procedural information, negotiation and other information (before 63.4 ± 22.5 / after 45.4 ± 24.2).	Medicine.	Cortisol was higher in the pre-simulation and lower in the post-simulation. Physiological levels remain high even when students are training more effectively.
	CG: non trained residents.	CG: 48		Salivary cortisol	Rest until end of preparation: (before 31.6 ± 14.0 / after 32.4 ± 18.4). End of preparation to end of simulation: (before 119.4 ± 57.2 / after 121.2 ± 66.5). End of simulation until 10 min recovery (before 56.4 ± 33.2 / after 54.9 ± 28.6). Recovery from 10 min to 30 min: (before 95.4 ± 53.4 / after 99.1 ± 48.2). Rest until 30 min recovery: (before 312.1 ± 152.3 / after 307.5 ± 159.4).	Objective performance: open and directed questions (before 3.3 ± 2.7 / after 2.8 ± 2.5). Support: recognition and empathy (before 24.2 ± 17.3 / after 22.3 ± 14.0). Information: procedural information, bargaining and other information (before 64.8 ± 29.0 / after 64.9 ± 28.5).	Medicine.

2012, Harvey et al., Canada(¹⁰10. Harvey A, Bandiera G, Nathens AB, LeBlanc VR. Impact of stress on resident performance in simulated trauma scenarios. J Trauma Acute Care Surg. 2012;72(2):497–503. doi: http://doi.org/10.1097/TA.0b013e31821f84be. PubMed PMID: 22439221. https://doi.org/10.1097/TA.0b013e31821f8... ).	IG: High-stress simulation (HS).	IG: 7	To examine the stress responses of residents during high and low stress simulated trauma resuscitations.	Salivary cortisol	+1,56 nmol/L(1,09).	Checklist: 43.6% (±3.2). GRS: 59.2% (±5.4). ANTS: 66.8% (±4.6). FHT: 60.5% (±3.75).	Medicine.	High-stress trauma simulation produced high cortisol levels and objective measures of stress and lower resident performance.
	CG: Simulação de baixo estresse (LS).	CG: 6		Salivary cortisol	–1,23 nmol/L (1,21).	Checklist: 48.0% (±2.6). GRS: 60.8% (±3.6). ANTS: 70.3% (±3.3). FHT: 68.6% (±2.8).	Medicine.

2012, Finan et al., Canada(⁶6. 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. doi: http://doi.org/10.1038/jp.2011.96. PubMed PMID: 22031045. https://doi.org/10.1038/jp.2011.96... ).	IG: High fidelity simulation. CG: Low fidelity simulation.	IG: 8 CG: 8	To compare the effects of HFS versus LFS technology on objective and subjective measures of stress in a group of neonatology trainees.	Salivary cortisol	Mean baseline level of 7.4 ± 3.7; peak of 14.9 ± 8.7 after the simulated event. Median change in cortisol over the simulations: 6.28 [1.94, 8.91], with no differences between the two groups (p < 0.001).	The mean overall performance score (NRP) was (75.85% ± 10.8) and the mean (ANTS) score was (2.86 ± 0.50). When comparing the groups, there was no significant difference in performance as measured by the (NRP) score (78.2% ± 11.7) (LFS) versus (HFS) (72.7% ± 9, p = 0.17).	Medicine.	The use of HFS and LFS technology resulted in an increase in subjective and objective stress measures. High-fidelity simulation offered no additional benefits in terms of stress modification.

2017, Bong et al., Singapore(²⁶26. 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. doi: http://doi.org/10.1097/SIH.0b013e3181e98b29. PubMed PMID: 21330809. https://doi.org/10.1097/SIH.0b013e3181e9... ).	IG: Training based on high-fidelity simulation (HFS).	IG:13	To explore the differences between stress levels and non-technical performance among trainees.	Salivary cortisol	Session 1: 0.12 µg/dL (0,05, 0,19) 0.05. Session 2: 0.07 µg/dL (0.001, 0.15) 0.03. Session 3: 0.09 µg/dL (0.01, 0.16) 0.05.	Session 1: 36.7 (34.6, 38.9). Session 2: 39.6 (37.5, 41.7). Session 3: 40.0 (37.9, 42.1).	Medicine, Nursing.	The observers of the immersive simulation-based training achieved an equivalent level of non-technical performance, while experiencing less stress than those repeatedly trained in the hot-seat.
	CG: Interactive educational training session.	CG: 14		Salivary cortisol	Session 1: –0.06 µg/dL (–0.13, 0.01) 0.02. Session 2: 0.01 µg/dL (–0.06, 0.08) –0.01. Session 3: 0.14 µg/dL (0.07, 0.22) 0.15.	Session 3: 39,4 (37.4, 41.5).	Medicine, Nursing.

2009, Muller et al., Germany(²⁷27. Müller MP, Hänsel M, Fichtner A, Hardt F, Weber S, Kirschbaum C, et al. Excellence in performance and stress reduction during two different full scale simulator training courses: a pilot study. Resuscitation. 2009;80(8):919–24. doi: http://doi.org/10.1016/j.resuscitation.2009.04.027. PubMed PMID: 19467753. https://doi.org/10.1016/j.resuscitation.... ).	IG: Crew resource management training (CRM).	IG: 17 CG: 12	Compare the effects of stress and performance in simulated resource management training and classical simulation training.	Salivary cortisol	Before: (12.5 ± 8.4). Immediately after: (15.9 ± 10.2). 15 minutes after: (19.5 ± 12.0).	Task management: pre (12.0 ± 4.3) / post (15.3 ± 3.4). Decision–making: pre (6.7 ± 2.4) / post (8.9 ± 2.3). General Performance: pre: (5.9 ± 2.0) / post: 7.4 ± 1.5)	Medicine.	Pre-simulation cortisol and salivary amylase values were higher compared to post-simulation. Cortisol concentration and salivary amylase activity showed a significant increase during the test scenarios.
	CG: Classical simulation training (MED).	CG: 12		Salivary cortisol	Before: (5.2 ± 2.7). Immediately after: (8.0 ± 6.0). 15 minutes after: (13.2 ± 12.2).	Task management: pre (12.0 ± 3.8) / post (14.7 ± 4.9). Decision–making: pre (6.7 ± 2.4) / post (8.6 ± 2.7). General Performance: pre (5.6 ± 1.6) / post: 6.6 ± 1.6).	Medicine.

2016, Lee et al., South Korea(²⁸28. Lee H, Park J, Kim S, Han J. Cortisol as a predictor of simulation-based educational outcomes in senior nursing students: a pilot study. Clin Simul Nurs. 2016;12(2):44–8. doi: http://doi.org/10.1016/j.ecns.2015.12.008. https://doi.org/10.1016/j.ecns.2015.12.0... ).	IG: Childbirth simulation.	IG:12	To investigate whether the emotional state, measured by salivary cortisol levels of final year nursing students, could predict their acquisition of knowledge and self-confidence.	Salivary cortisol	Conhecimento: B: 0.15 t: 2.63 (p = 0.17). Self–confidence: B: 0.10 t: 0.31 (p = .7590).	Conhecimento: 2.00 (1.13). Autoconfiança: 6.17 (6.00).	Nursing.	The students who took part in the childbirth simulation gained more knowledge and confidence and this was associated with higher cortisol levels.
	CG: Watching a video of the normal childbirth process.	CG: 11		Salivary cortisol		Knowledge: 0.18 (1.08). Self–confidence: 0.73 (5.31).	Nursing.

2013, Pottier et al., Belgium(²⁹29. Pottier P, Dejoie T, Hardouin JB, Le Loupp AG, Planchon B, Bonnaud A, et al. Effect of stress on clinical reasoning during simulated ambulatory consultations. Med Teach. 2013;35(6):472–80. doi: http://doi.org/10.3109/0142159X.2013.774336. PubMed PMID: 23464842. https://doi.org/10.3109/0142159X.2013.77... ).	IG: Low stress consultation (LS)	IG: 20	To evaluate the impact of subjective and physiological stress on the decision-making and communication skills of students in the context of outpatient consultations.	Salivary cortisol	Day 1: change of pre–scenario: 1.75 (1.01). Day 2: change from pre–scenario: 0.10 (0.73).	Overall communication: baseline: 64.9% (21.7) / study day: 69.7% (12.9). Clinical skills: baseline: 62.8% (15.0) / study day: 64.8% (10.8).	Medicine.	The study showed negative correlations between clinical reasoning and stress. Students who exhibited higher levels of subjective and physiological stress obtained fewer arguments for differential diagnoses.
	CG: High-stress consultation (HS)	CG: 21		Salivary cortisol	Day 1: change from pre–scenario: 1.51 (0.99). Day 2: change from pre–scenario: 3.63 (0.71).	Overall communication score: baseline: 55.7% (18.4) / study day: 68.2% (14.1). Clinical skills: baseline: 58.0% (11.5) / study day: 60.9% (10.9).	Medicine.

[1] Corresponding author: Jackson Gois Teixeira, Mc 01, Lot 43, Império dos Nobres Condomínio, 73252-105 – Sobradinho, DF, Brazil, jacksonudf1@gmail.com

Brasil

Brasil

Association between cortisol levels and performance in clinical simulation: a systematic review

Asociación entre los niveles de cortisol y el rendimiento en simulación clínica: revisión sistemática

ABSTRACT

Objective:

Method:

Results:

Conclusion: