The effect of clinical simulation assessment on stress and anxiety measures in emergency care students

To the Editor, We read with interest the research paper by C. Stein discussing the effect of clinical simulation assessment in emergency care students [1]. As UK medical undergraduates, we are very familiar with how pressurised this style of testing can be, which Stein identified. The methods used to assess stress were primarily measuring HRV variables and heart rate as a supporting objective measure. The author noted that there was an increased correlation between heart rate and anxiety. To support this finding, the author could have measured blood pressure, as there is an established relationship where a rise in blood pressure is seen in response to acute stress situations [2]. The results of both blood pressure and heart rate change would have strengthened the validity of the trend seen and been a better quantification of the impact of stress on autonomic activity. Stein's control scenario of allowing the students to sit alone for 15 min in a room could be improved upon by allowing those students to instead complete a problem-solving activity without a time limit or assessor, and measure HRV variables and perceived anxiety. This could allow for a better comparison, as it mirrors the assessment more closely, resulting in potentially more accurate HRV variable and State Trait Anxiety Inventory score results. The research paper made significant observations and collated empirical evidence in a field not previously explored; further research including the suggestions above would strengthen the findings.