Stress as tool or toxin: physiologic markers and subjective report in neonatal simulation

Redmond, B. L.; Joseph, Melissa; Ray, Jessica; Shabanova, Veronika; Gross, Isabel T; Bruno, Christie J.; McPadden, Jacob; Auerbach, Marc; Johnston, Lindsay

doi:10.1038/s41390-020-0806-9

Cited by 9 publications

(9 citation statements)

References 25 publications

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“…The Hexoskin smart shirt is a noninvasive device that continuously monitors the user’s cardiorespiratory function and activity using a variety of embedded sensors, including a 1-lead electrocardiogram (256 Hz). The smart shirt’s use has been reported in many peer-reviewed publications and validated to accurately obtain HRV data and its ability to serve as a surrogate marker of stress ( 17 , 18 , 30 ).…”

Section: Methodsmentioning

confidence: 99%

“…Stress impacts performance of technical procedures in medicine ( 17 , 18 ); however, the impact of physiologic stress on communication, the most commonly performed procedure, in pediatrics has not yet been explored ( 19 ). Most of the literature surrounding physician stress and discussion of serious news is based on subjective assessment combined with expert opinions.…”

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confidence: 99%

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Defining Objective Measures of Physician Stress in Simulated Critical Communication Encounters

Wolfe

Hinds

Plessis

et al. 2022

Critical Care Explorations

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This study had three aims: 1) quantify the difference in stress levels between low and high stress roles during simulated critical communication encounters using objective physiologic data (heart rate variability [HRV]) and subjective measures (State-Trait Anxiety Inventory [STAI]), 2) define the relationship between subjective and objective measures of stress, and 3) define the impact of trainee preparedness and reported self-efficacy on stress levels. DESIGN: Mixed methods simulation-based study. SETTING: Single center. PATIENTS: Pediatric critical care fellows and faculty (n = 12). INTERVENTIONS:Subjects participated in six simulated scenarios in both high stress "hot seat" and low stress "observer" roles. MEASUREMENTS AND MAIN RESULTS:Subjective stress was measured using the STAI at baseline and after each scenario. Objective stress was measured continuously using a wearable biometric device measuring HRV. Previous residency communication training and self-confidence surrounding various communication topics were collected via questionnaire. Significant changes in subjective (STAI) and objective stress (HRV) measurements in the low-versus high-stress roles were observed. STAI scores increased 8 points during low stress and 12 points during high stress role (p = 0.021) compared with baseline. Two specific HRV markers, root mean square of successive differences between normal heartbeats, a marker of parasympathetic tone, and the low frequency/high frequency (LF/HF) ratio, a marker of sympathetic activation, were significantly correlated with STAI levels (-0.032, p = 0.001; 1.030, p = 0.002, respectively). Participants who reported increased confidence in discussing code status had a significant decrease in stress response (measured via LF/HF ratio) during both the observer (p = 0.033) and hot seat roles (p = <0.001). CONCLUSIONS:Communicating life-altering news in a simulated environment is a stressful experience. This stress results in physiologic changes that can be measured continuously using HRV. HRV measurement may serve as a novel method in evaluating the effectiveness of communication training programs and measuring future stress-reduction interventions.

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Section: Methodsmentioning

confidence: 99%

mentioning

confidence: 99%

Defining Objective Measures of Physician Stress in Simulated Critical Communication Encounters

Wolfe

Hinds

Plessis

et al. 2022

Critical Care Explorations

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“…[14][15][16][17][18][19][20] In particular, heart rate variability (HRV), long recognized as a measure of autonomic nervous system activation, has been utilized as a correlate for stress and cognitive load. [21][22][23][24][25][26][27] It is a marker of the fluctuations of autonomic inputs, where an increase in sympathetic input leads to diminished variability. 22 The dynamic nature of this marker makes it well-suited to capture the moment-to-moment changes in autonomic nervous system during simulation and patient care.…”

Section: Introductionmentioning

confidence: 99%

“…The ability to induce physiologic stress using simulation, as measured by stress markers, physiologic measures, or self‐report questionnaires, has been well‐studied and, furthermore, it has been shown that the level of stress is comparable to the clinical setting 14‐20 . In particular, heart rate variability (HRV), long recognized as a measure of autonomic nervous system activation, has been utilized as a correlate for stress and cognitive load 21‐27 . It is a marker of the fluctuations of autonomic inputs, where an increase in sympathetic input leads to diminished variability 22 …”

Section: Introductionmentioning

confidence: 99%

All clinical stressors are not created equal: Differential task stress in a simulated clinical environment

Joseph

Ray

Chang

et al. 2022

AEM Education and Training

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Background: A variety of stressors are encountered while working in the emergency department and are often recreated in simulation-based medical education. We seek to examine the physiologic and stress state response of participants in a simulated clinical environment to commonly encountered stressors. Methods: Emergency medicine (EM) residents participated in a randomized, controlled trial of six simulated patient encounters with one of three stressors, medical difficulty, interpersonal challenge, and technology/equipment failure, randomized into each scenario. Participants wore smart shirts to measure heart rate variability (HRV) at rest and just after the introduced stressor and completed the Short Stress State Questionnaire (SSSQ) before and after each scenario.Results: Twenty-seven EM residents participated in the study. Interpersonal challenge resulted in increased distress as measured by SSSQ compared to the other two stressors (one way ANOVA, F[2,144] = 9.95, p < 0.001). There was no difference in worry or task engagement across stressors. HRV decreased significantly from rest for all stressors (p = 0.0003, p = 0.0112, p = 0.0027 for medical difficulty, interpersonal challenge, and equipment failure, respectively), but there was no statistically significant difference between mean change in HRV across stressors (one way ANOVA, F[2,120] = 0.17, p = 0.8452).Conclusions: Interpersonal challenge stressor was significantly associated with an increase in distress in EM residents during the simulated encounters as compared to the other stressors. While heart rate variability decreased from rest for each stressor as expected following stressor introduction, differing stressors did not produce a differential change.

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“…22,23 Studies have demonstrated that changes in HRV correlates with stress and cognitive load. [24][25][26][27][28] Therefore, the secondary aim of the research is to examine whether a correlation exists between physiologic measures from EM residents and the modified Angoff scores.…”

Section: Introduction/backgroundmentioning

confidence: 99%

A Novel Application of the Modified Angoff Method to Rate Case Difficulty in Simulation-Based Research

et al. 2020

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Introduction: Simulation use in research is often limited by controlling for scenario difficulty when using repeated measures. Our study assesses the feasibility of the Modified Angoff Method to reach expert consensus regarding difficulty of medical simulations. We compared scores with participant physiologic stress. Methods: Emergency medicine physicians with expertise in simulation education were asked to review 8 scenarios and estimate the percentage of resident physicians who would perform all critical actions using the modified Angoff method. A standard deviation (SD) of less than 10% of estimated percentage correct signified consensus. Twenty-five residents then performed the 6 scenarios that met consensus and heart rate variability (HRV) was measured. Results: During round 1, experts rated 4/8 scenarios within a 10% SD for postgraduate year 3 (PGY3) and 3/8 for PGY4 residents. In round 2, 6/8 simulation scenarios were within an SD of 10% points for both years. Intraclass correlation coefficient was 0.84 for PGY3 ratings and 0.89 for PGY4 ratings. A mixed effects analysis of variance showed no significant difference in HRV change from rest to simulation between teams or scenarios. Modified Angoff Score was not a predictor of HRV (multiple R 2 = 0.0176). Conclusions: Modified Angoff ratings demonstrated consensus in quantifying the estimated percentage of participants who would complete all critical actions for most scenarios. Although participant HRV did decrease during the scenarios, we were unable to significantly correlate this with ratings. This modified Angoff method is a feasible approach to evaluate simulation difficulty for educational and research purposes and may decrease the time and resources necessary for scenario piloting.

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Stress as tool or toxin: physiologic markers and subjective report in neonatal simulation

Cited by 9 publications

References 25 publications

Defining Objective Measures of Physician Stress in Simulated Critical Communication Encounters

Defining Objective Measures of Physician Stress in Simulated Critical Communication Encounters

All clinical stressors are not created equal: Differential task stress in a simulated clinical environment

A Novel Application of the Modified Angoff Method to Rate Case Difficulty in Simulation-Based Research

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