Assessment of psychological stress on the clinical performance experienced by paramedic students during clinical assessments
Authors:   , Ismail Erefaan 
Published: April 2024

Background This study presents a comprehensive insight into the degree of psychological stress experienced by paramedic students during clinical assessments. Available evidence shows that high anxiety levels may impact performance negatively, which can lead to poor patient safety outcomes. To achieve the objectives of the study, multiple validated psychological and physiological biometric tools were utilised to generate the most accurate and ‘complete’ stress profiles for this cohort to date. Methodology At a specific university, the total undergraduate Bachelor’s Emergency Medical Care (BEMC) student population was (n) 83 students, of which (n) 56 enrolled as voluntary participants to form the experimental group. Data collection occurred during this cohort’s final-term clinical assessments. Meanwhile for comparison, the control group’s data (n 15) was collected during their clinical simulations practice in class (non-assessment conditions). Psychological stress was measured using the validated State-Trait Anxiety Inventory Questionnaire and concurrently, the following stress indicators were utilised to capture the participants’ physiological biomarkers, which included saliva samples (for both α-amylase and cortisol assay), heart rate, respiration rate, as well as heart rate variability, as recorded by the Hexoskin smart vest’ connected platform. To the author’s knowledge, it was the first time in Africa that this biometric online technology was utilised to capture respiration and cardiovascular stress biomarkers in this context. Results The State-Trait Anxiety Inventory results showed a strong positive correlation between the Y2 scores before and after assessment (r = 0.78). In addition, there was a moderate positive correlation (r = 0.78, p = <0.001) between the total State-Trait Anxiety Inventory score, before assessment and the total State-Trait Anxiety Inventory score after assessment, meaning the participants experienced elevated anxiety levels at each point in time. The majority who indicated they experienced elevated anxiety levels (87.5%; n = 49), showed a linear relationship between their measured biomarkers and State-Trait Anxiety Inventory anxiety scores. For example, a statistically significant association was observed between the Y2 scores and RR, for the period after the experiment, particularly in the group with a Y2 score of >40. When the data was stratified by year of study, a similar significant association occurred between the State-Trait Anxiety Inventory scores and observed RR (p<0.001). The mean heart rate for the exposed group were significantly higher (p = 0.026) for the before and during assessments, but not after the assessments (p = 0.2), when compared to the mean HR for the control group. The experimental groups’ Heart Rate Variability (only standard deviation of normal-to-normal R-R intervals method) during the assessments were significantly higher than the control group (p = 0.020). However, there were also exceptions to this linear relationship ‘rule’, specifically related to the salivary assay results, where the findings of the α-amylase assay over time (before and after assessment), revealed that the enzyme levels of the enzyme decreased over time, although the change in concentration was not statistically significant (p = 0.31). In contrast, there was a significant difference in the cortisol assay results of the first year group, in comparison to the groups of other years, both their before- (p = 0.006) and after-experiment results (p = 0,003). Conclusion The study findings highlighted that both the control and experimental groups were exposed to clinical simulation-based learning environments which predisposed them to elevated anxiety levels (before, during and after these activities), which may impact learning and performance negatively. Ultimately, students must develop the ability to integrate their cognitive ability, specialised practical knowledge and ethical awareness, including stress management skills into clinical practice to become caring and professional healthcare providers (paramedics).