Stress and Its Impact on the Clinical Performance of Health Professionals

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Stress and Its Impact on the Clinical Performance
of Health Professionals
Vicki R. LeBlanc, Ph.D.
Ontario Air Ambulance Base Hospital Program
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Stress and Health Professionals

• Health professionals face many stressors in their
  work environment
• Sleep deprivation
• Disruptions in social support
• Clinical vs. educational conflicts
• Caring for critically ill or dying patients
• Certification or licensing examinations
• Documented link between stress and mental health
• Higher than normal levels of depression and
  anxiety
• (French et al., 1982 Peterlini et al.,
  2002)

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Stress and Health Professionals

• Some stressors will always exist
• i.e. caring for critically ill and/or rapidly
  deteriorating patients
• Little research on impact of acute stress on the
  abilities necessary for patient care
• Processing Information
• Vigilance
• Pattern Recognition
• Memory
• Decision making
• Motor skills

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Goals of Research Program

• Identify effects of stress on performance
• During patient treatment
• During learning/training
• Identify Mediating Factors
• Develop and implement interventions
• Training stress management/inoculation
• Technology
• Mixed findings in laboratory settings
• Conflicting findings between laboratory settings
  and naturalistic settings

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Concept of Stress

• Physiological Process
• Selye (1993) result of any demand on the body
• Stress response is the same, regardless of type
  of stress or nature of the demands
• Yerkes-Dodson Law Inverted U relationship
  between stress and performance

Performance
Arousal
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Concept of Stress

• Physiological description insufficient
• Lazarus (1993) appraisal and coping
• Stress is not simply an environmental stimulus
  nor purely a characteristic of the individual.
• Stress is the interaction between
• Requirements that tax or exceed an individuals
  resources and,
• The individuals ability to cope with those
  requirements
• Psychological component anxiety

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Stress and Cognitive Performance

• Psychology laboratories mixed results
• Broadened attention span vs. narrowed attention
• Impaired memory vs. detailed and accurate memory
  for central details
• Impaired decision making vs. adaptive decision
  making
• Johnston, Driskell Salas (1997)
• Naturalistic research
• Mediators of effects of stress
• Familiarity with the task or stressor
• Consequences of errors
• Liberman et al, (2002)
• U.S. Navy S.E.A.L. trainees duringHell Week
• Impaired visual scanning, reaction time, and
  memory.
• Cumming Harris (2001)
• Medical radiation students

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Stress and Cognitive Performance

• Liberman et al, (2002)
• U.S. Navy S.E.A.L. trainees 72 hours into Hell
  Week showed impairments in visual scanning,
  visual reaction time, and memory.
• Cumming Harris (2001)
• Impairments in performance on decision task by
  medical radiation students due to naturalistic
  and experimentally induced anxiety.
• Stressor not clinically related
• Very little published research in the health
  professions

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StudyParamedic Performance Under Stress

• Stress levels related to challenging clinical
  scenarios
• Enhance or impair performance of tasks related to
  every-day job responsibilities?
• Flight Paramedics
• Care for critically ill or injured patients
  during transport.
• Everyday responsibilities include drug
  calculations and administration

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Research Goals

• Two research questions
• Does the anxiety caused by stressful paramedic
  scenarios impair paramedics mathematical
  performance?
• -drug calculations
• Do training and experience mediate the impact of
  stress on paramedics mathematical performance?
• -stress response
• -performance vulnerability to stress response

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Participants

• Flight Paramedic Students
• 18 Advanced Care Flight Paramedicine ACP(F)
• patient assessment, basic trauma care, symptom
  relief medication (nitroglycerin)
• EKG interpretation, 15 emergency medications (i.e
  dopamine)
• 12 Critical Care Flight Paramedicine CCP(F)
• Highest level of paramedic certification in
  Canada
• Administer an extensive list of medication

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Research Design
Pre-study survey - Training - Experience
Low-stress Classroom - State anxiety
- Mathematical problems

High stress Simulator - State anxiety -
Mathematical problems
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Human Patient Simulator

• Mannequins
• heart rate
• pulse in the limbs
• breath sounds
• dilating pupils

• Patient care areas of
• Type III land ambulance
• Sikorsky S-76 helicopter

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Outcome Measures

• Manipulation Check
• State -Trait Anxiety Inventory (STAI)
• 20 items on a 4-point scale
• I feel strained 1 2 3 4
• I feel upset 1 2 3 4
• I feel secure 1 2 3 4
• Range 20 80

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Outcome Measures

• Accuracy on written math problems
• Arithmetic (8)
• 1234 13x3
• Medical (6)
• Versed is supplied 5mg in 5ml. How many ml will
  you administer to give 0.7mg?

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Outcome Measures

• Accuracy on written math problems
• Arithmetic (8)
• 1234 13x3
• Medical (6)
• Versed is supplied 5mg in 5ml. How many ml will
  you administer to give 0.7mg?
• Set 1 and Set 2
• Piloted and matched for difficulty

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Results Anxiety Levels
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Results Anxiety Levels
Working adults
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Results Anxiety Levels
Simulated exam
Working adults
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Results Anxiety Levels
Movie depicting work accidents
Simulated exam
Working adults
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Arithmetic Problems
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Medical Mathematical Problems
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Mediating Effect of Experience?

• Years of experience did not predict scores on
  anxiety assessment
• R2.12, p.2
• Years of experience did not predict performance
  impairments
• R2.09, p.3 for arithmetic problems
• R2.14, p.13 for medical problems

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Conclusions

• Stress-induced anxiety has a negative impact on
  mathematical performance
• moderately difficult
• necessary in every day paramedic performance
• Neither training nor experience mediate
• the stress response
• the vulnerability of performance to the stress
  response.

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Limitations

• Stressor temporally separate from the task
• Future study incorporate task into the scenario
• Component of evaluation stress
• Raises question of effects of various stressors
  on performance
• Task contingent stress (task itself)
• Peripheral stress (noise, being evaluated)

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Summary

• Stress impaired ability to calculate drug dosages
• Experience and training do not appear to mediate
  effects of stress
• Next Steps
• Comparing effects of various sources of stress
• Investigating predictors of performance under
  stress

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Thanks to

• Support
• Dr. Chris Mazza (CEO - Ontario Air Ambulance Base
  Hospital Program)
• Physician Services Incorporated Foundation
• Colleagues
• OAABHP University of Toronto
• Dr. Russell MacDonald Dr. Glen Bandiera
• Brad McArthur Dr. Adam Dubrowski
• Tom Lepine Aarti Juneja
• Kevin King Howard An