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Stress and Its Impact on the Clinical Performance of Health Professionals

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

  2. 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)

  3. 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

  4. 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

  5. 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

  6. 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

  7. 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

  8. 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

  9. 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

  10. 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

  11. 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

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

  13. Mannequins: heart rate pulse in the limbs breath sounds dilating pupils Patient care areas of: Type III land ambulance Sikorsky S-76 helicopter Human Patient Simulator

  14. 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

  15. 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?

  16. 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

  17. Results: Anxiety Levels

  18. Results: Anxiety Levels Workingadults

  19. Results: Anxiety Levels Simulatedexam Working adults

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

  21. Arithmetic Problems

  22. Medical Mathematical Problems

  23. 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

  24. 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.

  25. 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)

  26. 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

  27. 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