Pressure Points

Introduction: Simulation-based education plays a central role in preparing health care professionals for practice. Although psychological safety is emphasized, simulation can evoke significant stress. Existing research largely captures global or retrospective stress measures, offering limited insight into how stress unfolds during simulation. This study examined patterns of physiological stress in final-year medical students during simulated clinical scenarios, identified activities associated with heightened stress, and characterized inter-individual variability in stress trajectories. Methods: In this prospective observational study, 40 final-year medical students individually managed an acutely deteriorating simulated patient during formative ward-based scenarios. Heart rate variability was continuously recorded using Polar H10 chest straps, and the Stress Index was calculated in 10-second segments. Video recordings were time-matched to physiological data and coded into 16 clinical activities. Mixed-design analysis of variance examined differences in stress across activities and scenario phases (anticipation, start, during, presenting). Results: Stress varied significantly across participants (η 2 = 0.40) and activities (η 2 = 0.06), with a significant participant-by-activity interaction (η 2 = 0.26). Higher stress occurred during activities involving uncertainty and socioevaluative elements (heading to the simulation room, receiving nurse handover, presenting to senior clinician, gathering additional information during questioning). Lower stress occurred during history taking, physical examination, and ordering investigations. Stress was highest during the “start and anticipation” phases and lower “during and presenting.” Learner clusters showed phase-specific stress patterns. Conclusions: Physiological stress during simulation is dynamic, individualized, and clustered around identifiable “pressure points.” These findings extend simulation research beyond global measures and highlight the importance of simulation facilitation that recognizes individual variability in learners’ experiences.