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

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)

Professionals 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

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

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 Arousal Performance

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 individual’s resources and, The individual’s ability to cope with those requirements Psychological component; anxiety

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 during“Hell Week” Impaired visual scanning, reaction time, and memory. Cumming & Harris (2001): Medical radiation students Impaired during decision-making task No published research in pre-hospital context

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

Study: Paramedic 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

Research Goals: Two research questions: 1. Does the anxiety caused by stressful paramedic scenarios impair paramedics’ mathematical performance? -drug calculations 2. Do training and experience mediate the impact of stress on paramedics’ mathematical performance? -stress response -performance vulnerability to stress response

ParticipantsParticipants 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

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

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

Outcome Measures Manipulation Check: –State -Trait Anxiety Inventory (STAI) 20 items on a 4-point scale: I feel strained I feel upset I feel secure Range: 20 – 80

Outcome Measures Accuracy on written math problems: Arithmetic (8): –12+34; 13x3 Medical (6): –Versed is supplied 5mg in 5ml. How many ml will you administer to give 0.7mg?

Outcome Measures Accuracy on written math problems: Arithmetic (8): –12+34; 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

Results: Anxiety Levels

Working adults Results: Anxiety Levels

Working adults Simulated exam Results: Anxiety Levels

Movie depicting work accidents Working adults Simulated exam Results: Anxiety Levels

Arithmetic Problems

Medical Mathematical Problems

Mediating Effect of Experience? Years of experience did not predict scores on anxiety assessment: R 2 =.12, p=.2 Years of experience did not predict performance impairments: R 2 =.09, p=.3 for arithmetic problems R 2 =.14, p=.13 for medical problems

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.

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)

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

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 KingHoward An