The Effect of Assessor Presence on Stress and Anxiety Experienced During Clinical Simulation-Based Assessment

Background: Emergency medical care (EMC) has been recognised as an important sector within public health care by the World Health Organisation. Emergency medical care refers to the provision of initial resuscitation, stabilisation, and treatment to acutely ill and injured patients and delivering those patients to the best available definitive care (AFEM Consensus Conference, 2013).
As part of teaching and learning methods for emergency care education, clinical simulation-based learning has traditionally been used to train and assess EMC students. Clinical simulation has proven to be a valuable tool for EMC students to prepare them for the real pre-hospital work environment. Many EMC programmes use clinical simulations to assist EMC students in learning the roles and responsibilities of the pre-hospital emergency care providers. These teaching tools include the use of a simulated clinical environment in which students practise with manikins or actors as patients, and may include being observed by assessors, cameras, moderators and their peers, especially during simulation-based assessments.
Clinical simulation-based assessment is now acknowledged as an effective strategy to improve and support the development of confidence and competence, yet it also presents challenges for EMC students, such as anxiety and stress (Taylor, 2017; Burke & Mancuso, 2012) as with all forms of assessment (Childs & Sepples, 2006; Stecz et al.,2021; Muldoon, Biesty & Smith, 2014). The presence of assessors in the clinical simulation assessment venue has been reported as one of the possible sources of stress and anxiety among students during clinical simulation-based assessment (Mills et al., 2016). Despite some evidence that students are stressed and anxious in the presence of assessors in the simulation venue, which may, in turn, have a negative effect on students’ performance, the experiences of students enrolled in the BHSc EMC (Bachelor of Health Science in Emergency Medical Care) programme in South Africa remains unknown.
Methods: This study was prospective, quantitative experimental research with a repeated measures design. The four dependent variables were heart rate variability (three specific variables, two time domain, and one frequency domain), salivary alpha-amylase levels, salivary cortisol levels, and State-Trait Anxiety Inventory scores. The single independent variable was a binary grouping variable indicating whether simulation assessors were in the assessment venue (visible to participants) or not. Each participant was exposed to both groups, and their dependent variable measurements were compared, hence the repeated measures design. Data analysis involved descriptive analysis, principally by group (control or experimental) and within groups by academic year of study. In addition to group comparison, each student served as their own control (i.e., student A with assessor presence was compared to student A without assessor presence).
Results: The results of this study revealed no significant paired differences in anxiety scores between assessor-present and assessor-absent groups. Of the four HRV variables included for analysis in this study, only heart rate was significantly different between assessor-present and -absent groups. Mean heart rate in the assessor-absent group was significantly higher than that in the assessor-present group. None of the salivary alpha-amylase paired differences were significant. Of the four paired salivary cortisol comparisons, only the pre- vs post-test difference in the assessor-absent group was significant. While there were few significant differences between groups, mean and median values for all of the variables between assessor groups exhibited unexpected patterns.
Conclusion: This study demonstrated inconclusive results; therefore, no specific recommendations could be made. Due to the inconclusive results of this research, it is recommended that both simulation-based assessment methods (the traditional method of assessment with assessors present in the simulation venue and the more recently introduced method with assessors absent from the simulation venue) may continue to be utilised.