Impact of stress on resident performance in simulated trauma scenarios

J Trauma Acute Care Surg. 2012 Feb;72(2):497-503. doi: 10.1097/ta.0b013e31821f84be.


Background: Training and practice in medicine are inherently stressful. The effects of stress on performance in clinical situations are poorly understood. The purpose of this study was to examine the stress responses and clinical performance of residents during low and high stress (HS) simulated trauma resuscitations.

Methods: Thirteen emergency medicine and general surgery residents were evaluated in HS and low stress (LS) trauma resuscitation simulations. Subjective and physiologic (heart rate, salivary cortisol) responses were measured at baseline and in response to the scenarios. Performance was assessed with global rating and checklist scores of technical performance, time to record critical information, and the Anesthesia Non-Technical Skills tool. Post-scenario recall was assessed with the completion of a standardized trauma history form.

Results: Post-scenario subjective stress and cortisol levels were higher in the HS scenario compared with the LS scenario (p < 0.05). Checklist performance scores and post-scenario recall were significantly lower in the HS compared with the LS condition (p < 0.05).

Conclusion: In trainees, some aspects of performance and immediate recall appear to be impaired in complex clinical scenarios in which they exhibit elevated subjective and physiologic stress responses. The findings of this study highlight a potential threat to patient safety and demand further investigation. Future studies should strive to further elucidate the effects of stress on specific components of performance and investigate ways to reduce its negative impact.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Analysis of Variance
  • Clinical Competence*
  • Emergency Medicine / education*
  • Female
  • Glasgow Coma Scale
  • Heart Rate / physiology
  • Humans
  • Hydrocortisone / analysis
  • Internship and Residency*
  • Male
  • Patient Simulation*
  • Stress, Psychological / physiopathology*


  • Hydrocortisone