Simulate to stimulate? A systematic review of stress, learning, and performance in healthcare simulation

In recent years, simulation has come to prominence as an educational method within the healthcare professions, aiming to shield learners from real-world consequences. However, the associated risks of this educational method have largely remained unaddressed. One of the most potent risks of simulation is felt to be the experience of psychological stress. Over the last two decades, researchers have suggested that an increase in simulation-related stress goes hand-in-hand with diminishing performance, but the evidence base for this claim is lacking. A medical educator thus has no robust scientific steering on which to gauge how 'hard to push' a trainee in a simulation environment to best assist their learning. In this review we systematically analyse the literature to further understand the impact of simulation-related stress on learner performance and report that inducing a high-stress environment during simulation is generally associated with impaired performance.