Measurement of physiological responses to acute stress in multiple occupations: A systematic review and implications for front line healthcare providers

Measurement of physiological responses to acute stress in multiple occupations: A systematic... Abstract Optimizing performance of individuals in acutely stressful work-related situations requires a deeper understanding of the interaction between the demands of the stimuli and an individual’s associated physiological response. Identifying these responses is particularly germane for healthcare professionals, who experience episodes of acute stress on a regular basis. The purpose of this review was to examine and synthesize empirical literature to identify studies assessing physiological responses to acute stress, determine common methods for measuring acute stress in near real-time, and identify common research designs employed across industries. A modified PRISMA approach was followed. Systematic searches were conducted of four databases (PsycINFO, Medline, PubMed, and Turning Research into Practice [TRIP]) to access eligibility. Reference list searches and a hand search were also conducted to identify other articles suitable for inclusion. Studies selected examined an acute physiological response while participants were engaged in a stress-inducing task. Twenty-two articles were included. Fifteen (68.2%) were centered on the human service industry while only three (13.6%) focused on healthcare professionals. Half of the studies incorporated a simulation into the research design while only two (9.1%) articles looked at physiological responses in real-world settings. Heart rate and cortisol emerged as the most common physiological measures collected. This review demonstrates that acute stress is primarily assessed retrospectively, and that there is a pragmatic gap in methodological approach, with many data collection methods inappropriate for the healthcare environment. Future research should capitalize on advancements in sensor technology to passively examine acute stress in healthcare professionals. Implications Practice: Management of the effects of acute stress while actively engaged in work-related tasks may improve the performance of healthcare providers which is directly related to patient care. Policy: This paper can inform organizational leaders on the benefits of supporting acute stress management strategies to promote a sense of health and wellness and a culture of safety. Research: Future research on acute stress in healthcare providers can employ methodology to conduct in situ studies using noninvasive and passive measures to proactively identify negative physiological reactions to acute stress that may lead to performance decrement in the workplace. INTRODUCTION Work stress and human performance The relationship between stress and the work environment has been a topic of study for the last century [1]. Employed adults between 25 and 54 years of age spend almost 9 hr on an average weekday engaging in work or work-related activities, making this topic highly relevant across professions [2]. Occupational stress “arises from demands experienced in the working environment that affect how one functions at work or outside work” [3]. Acute stress, defined by the American Psychological Association (APA) as “demands and pressures of the recent past and anticipated demands and pressures of the near future,” is characterized as a brief, event-based phenomenon [4]. Because of its fleeting nature, acute stress represents an aspect of occupational stress that could be managed with preventative approaches in order to optimize performance of employees across work settings. Present day interpretations of the classic Yerkes-Dodson law state that higher amounts of stress can, to a point, lead to a higher level of performance [5]. If the optimal point is exceeded, in moments of acute stress for example, task performance and decision-making abilities could become impaired followed by a decline in performance quality [6]. This decrement in performance is due in part to the inhibition of executive functions, particularly working memory, which can block an individual experiencing acute stress from recruiting past and present resources to aid in performing at an ideal level [7]. The stress response is known to vary according to the nature of the stressor, perception of the severity of the stressor, and factors inherent to each individual with acute stress representing a shorter duration of the stress response [8]. Because of the dynamic nature of stress, assessing an individual’s response during well-defined episodes of acute stress could be a key method to finding the balance between the detrimental effects of stress and optimal performance. In episodes of acute stress, the cognitive appraisal of the stressor dictates the response to the stressor. For example, a challenge response results when the individual perceives the ability to cope with the demands of the situation whereas a threat response results when situational demands are appraised to surpass the available resources inhibiting the individual to cope with the demands [9]. Threat responses to acute stress could lead to subsequent impairments in performance outcomes. Acute stress in healthcare workers Performance decrement within healthcare providers has significant implications not only for patients, but for the providers themselves. Work demands in the healthcare sector are increasing and becoming more complex with advances in technology, the rising prevalence of chronic diseases, the aging baby boomer population, and the expansion of individuals currently covered under the Affordable Care Act [10–12]. These baseline changes in the day-to-day stress of a healthcare provider could potentially increase the magnitude of acute stress in response to an additional stress-inducing task. Previous literature has investigated concepts of occupational stress within healthcare providers [13, 14] and observable changes indicative of strain have been noted to occur over time [15]. With the relationship between acute stress and performance established, adding the high risks common to a healthcare work setting could substantially compound performance decrement. Because eliminating acute stress is not an appropriate option, training protocols that incorporate acute stress management strategies represent a promising area of research that could be applied to the healthcare sector [16]. In response to the ever-changing demands of their job role, healthcare professionals could potentially learn to mitigate their reactions, and therefore negative consequences, to acutely stressful situations [17]. Reducing negative reactions to stress is desirable because an inappropriate response to acute stress has implications beyond individual cognition; it threatens the performance of an entire team. Previous literature has established that the emotions and behaviors of one person can transfer to another person and unconsciously trigger parallel emotions and behaviors in a phenomenon that is referred to as stress contagion [18, 19]. Therefore, an individual provider reacting negatively to acute stress could affect other members of the healthcare team, creating a cycle of performance decrement. Because delivery of high quality healthcare is dependent on effective teamwork, promoting positive reactions to acute stress could benefit individual providers, their colleagues, and most importantly, patients. Measuring acute stress Stress is a state that cannot be directly observed yet affects performance [5]. Evaluation of an individual’s physiological response while experiencing high mental demands with subsequent inference on performance quality is an established concept [20]. Advancements in sensor technology have broadened the number of physiological measures that can be reliably recorded in an unobtrusive and passive manner. Additionally, these measures can be recorded in real-time and in settings outside of a highly controlled research laboratory [21]. Studying acute stress in the real-world ensures an accurate representation of the stressors experienced in daily work life and provides assurance that the stressors encountered will be meaningful to participants [22]. Monitoring physiological responses in real-time secures the capture of response patterns indicative of acute stress and could reveal proactive starting points for intervening to optimize performance under stress [16]. Real-time monitoring also potentially allows researchers to immediately capture biological responses and impart a degree of exactness in the relationship between stimuli and response [20, 22]. This systematic review aims to identify previous empirical research focused on acute stress in working professionals. The results will be interpreted with an emphasis placed on the implications for the healthcare sector. As healthcare providers are expected to make accurate clinical judgments that lead to improved patient care, it is critical to explore their performance in real-time under acute stress. Our specific research questions included: What are the commonly employed measures, both subjective and objective, to record acute changes in physiology related to acute stress? How does acute stress impair performance in defined occupations? METHODS Study identification To ensure we were examining an acute stress response, we focused on articles that assessed markers of stress in near real-time to a clearly defined stress-inducing task. We were also interested in passive measurement mechanisms, since our goal population for application is healthcare providers, and any employed methodology cannot interfere with patient care. Although not an inclusion criterion, we ensured that each article contained at least one physiological measure associated with acute stress reactivity. Those included heart rate (HR), heart rate variability (HRV), and cortisol [23–25]. We operationalized near real-time in accordance to these three measures such that HR and HRV would be monitored before, during, and after the stress-inducing task. For cortisol responses, assessment no later than 40 min after cessation of task was deemed appropriate to capture peak responses [25]. Systematic searches were conducted in February 2017 on the following electronic databases: PsycINFO, PubMed, Medline, and TRIP (Turning Research into Practice). The TRIP database was selected to expand the number of international journals and publications searched. After extensive browsing in each database and after consultation with a clinical research librarian, the authors created search terms unique to each database in an effort to maximize the number of occupations represented in the search results. Additionally, Medical Subject Headings (MeSH) were used for our search within PubMed and Medline to assist with refining our search results. Full electronic search strategies can be found in Supplementary Material 1. Study selection Inclusion criteria for articles were: (i) published in the English language, in a peer-reviewed journal, (ii) specified as containing a physiological measure, (iii) measure was reflective of acute stress, (iv) occupation of participants was clearly stated (i.e., not students), (v) human subjects, adult age groups, (vi) and written within the timeframe of January 1, 2007 to January 31, 2017. We only searched articles from the past 10 years in an effort to review articles that would reflect technological advancements in the field of passive physiological monitoring. Exclusion criteria included: undergraduate students, broadly defined subject groups, only subjective reports of stress from participants, interventions that require specialized credentials (e.g., prescription drugs), patients as participants, and documented diagnoses in participants that could alter stress response (i.e., depression, anxiety, and post-traumatic stress disorder). Between the four databases, 482 articles were identified with our search terms. After duplicate articles were removed, 448 records remained. All 448 titles and abstracts were independently assessed by two reviewers (S.E.F. and a novice second reviewer) for eligibility to reduce bias in the selection process. Any disagreements were discussed and resolved until a consensus was reached; 40 abstracts were found to meet our inclusion criteria. The collection of articles was further reduced to a total of 15 once the full-text of the articles was reviewed. A third reviewer (S.H.P.) independently reviewed all 15 articles and confirmed eligibility. We analyzed the reference sections of these articles and performed hand searching to find an additional seven articles that met inclusion criteria to increase the number of articles included to 22 in total. Data extraction We presumed study participants worked full-time (30 plus hours per week) in the stated occupations unless otherwise noted. The first author of one study was contacted via e-mail to clarify study results. The principal summary measure was a change in baseline physiological measures in the context of responding to a discrete stress-inducing task. Additional key characteristics from each study were identified by the authors prior to database searches. These items were extracted from each study and compiled into a structured spreadsheet (see Supplementary Material 2). Whenever applicable, the process used in this review followed the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) Statement to reduce bias and improve the quality of reporting [26]. We modified the PRISMA approach by not assessing the risk of bias across studies or reporting outcomes related to interventions within the studies as these points were unrelated to the research questions. RESULTS The screening process is summarized using the PRISMA diagram (see Fig. 1). An overview of study characteristics can be found in Table 1. Table 1 Overview of 22 articles assessing acute stress in defined occupations Characteristics  Number of studies (%)  Occupational Category  Human Services  15 (68.2)   Firefighters  7   Police officers  4   Teachers  3   Soldiers  1  Healthcare  3 (13.6)   Residents  1   Nurses and Nursing Assistants  1   Surgeon  1  White collar  3 (13.6)   Senior office managers  2   Office workers  1  Entertainment  1 (4.5)   Orchestra Musicians  1  Country of Study  United States  9 (40.9)  Europe  7 (31.8)  South Africa  2 (9.1)  Australia  2 (9.1)  China  1 (4.5)  Canada  1 (4.5)  Study Setting  Simulation  11 (50)  Laboratory  7 (31.8)  Real-world  2 (9.1)  Laboratory and Real-world  1 (4.5)  Simulation and Laboratory  1 (4.5)  Gender of Participants  Males and Females  14 (63.6)  All males  6 (27.3)  All females  1 (4.5)  Unknown  1 (4.5)  Characteristics  Number of studies (%)  Occupational Category  Human Services  15 (68.2)   Firefighters  7   Police officers  4   Teachers  3   Soldiers  1  Healthcare  3 (13.6)   Residents  1   Nurses and Nursing Assistants  1   Surgeon  1  White collar  3 (13.6)   Senior office managers  2   Office workers  1  Entertainment  1 (4.5)   Orchestra Musicians  1  Country of Study  United States  9 (40.9)  Europe  7 (31.8)  South Africa  2 (9.1)  Australia  2 (9.1)  China  1 (4.5)  Canada  1 (4.5)  Study Setting  Simulation  11 (50)  Laboratory  7 (31.8)  Real-world  2 (9.1)  Laboratory and Real-world  1 (4.5)  Simulation and Laboratory  1 (4.5)  Gender of Participants  Males and Females  14 (63.6)  All males  6 (27.3)  All females  1 (4.5)  Unknown  1 (4.5)  View Large Table 1 Overview of 22 articles assessing acute stress in defined occupations Characteristics  Number of studies (%)  Occupational Category  Human Services  15 (68.2)   Firefighters  7   Police officers  4   Teachers  3   Soldiers  1  Healthcare  3 (13.6)   Residents  1   Nurses and Nursing Assistants  1   Surgeon  1  White collar  3 (13.6)   Senior office managers  2   Office workers  1  Entertainment  1 (4.5)   Orchestra Musicians  1  Country of Study  United States  9 (40.9)  Europe  7 (31.8)  South Africa  2 (9.1)  Australia  2 (9.1)  China  1 (4.5)  Canada  1 (4.5)  Study Setting  Simulation  11 (50)  Laboratory  7 (31.8)  Real-world  2 (9.1)  Laboratory and Real-world  1 (4.5)  Simulation and Laboratory  1 (4.5)  Gender of Participants  Males and Females  14 (63.6)  All males  6 (27.3)  All females  1 (4.5)  Unknown  1 (4.5)  Characteristics  Number of studies (%)  Occupational Category  Human Services  15 (68.2)   Firefighters  7   Police officers  4   Teachers  3   Soldiers  1  Healthcare  3 (13.6)   Residents  1   Nurses and Nursing Assistants  1   Surgeon  1  White collar  3 (13.6)   Senior office managers  2   Office workers  1  Entertainment  1 (4.5)   Orchestra Musicians  1  Country of Study  United States  9 (40.9)  Europe  7 (31.8)  South Africa  2 (9.1)  Australia  2 (9.1)  China  1 (4.5)  Canada  1 (4.5)  Study Setting  Simulation  11 (50)  Laboratory  7 (31.8)  Real-world  2 (9.1)  Laboratory and Real-world  1 (4.5)  Simulation and Laboratory  1 (4.5)  Gender of Participants  Males and Females  14 (63.6)  All males  6 (27.3)  All females  1 (4.5)  Unknown  1 (4.5)  View Large Fig. 1 View largeDownload slide PRISMA diagram on systematic review of literature. Fig. 1 View largeDownload slide PRISMA diagram on systematic review of literature. Overview of studies In many of the studies, the authors attempted to approximate a real-world scenario relevant to the designated occupation under study with an added controlled, but still acutely stressful stimuli (e.g., shoot/don’t shoot task in police officers). Studies were primarily conducted in the USA followed by Europe. Simulation was the most common research setting. The majority of the studies used both male and female participants. The sample sizes in the studies ranged from one to 198, with an average sample size of 62 participants. The study with one participant was looking at the impact of surgical procedure type on physiological response and perceived workload changes in a total of 48 surgeries. The single participant design was a conscious decision by the authors to eliminate interpersonal variability, a common challenge in interpreting results of psychophysiological studies. More than half of the studies were centered on the human services industry. Within this category, firefighters were the predominant profession under investigation with a live firefighting simulation as the acute stress-inducing task. Only three articles were focused on the healthcare industry. Two articles were assessing the pre and post effects of an intervention that could be applicable to the healthcare setting, biofeedback [27, 28]. It appears these articles are from the same data collection period but the results were published in two separate articles. In addition, two articles studying firefighters in Australia appear to be from the same data collection [29, 30]. Table 2 summarizes physiological and subjective measures employed in two or more studies. Detailed reporting of characteristics and results for each study can be found in Supplementary Material 2. Table 2 Summary of objective and subjective measures employed in at least two studies Physiological measures  Number of studies  Heart rate  15  Cortisol  14   salivary  11   serum  2   both  1  Blood pressure  7  Heart rate variability  6  Respiratory rate  4  Core body temperature  4  Interleukin (IL)-6  3  Serum inflammatory markers  3  Serum coagulation factors  3  Serum norepinephrine  2  Salivary alpha amylase  2  Serum glucose  2  Subjective measures  Number of studies  State-Trait Anxiety Inventory  4  Fatigue/Sleepiness Scalesa  4  Perceived stressfulness of task  4  Depression Scalesb  3  Chronic Job strain Scalesc  3  Perceived physical exertion of task  2  Smith Relaxation States Inventory 3  2  Physiological measures  Number of studies  Heart rate  15  Cortisol  14   salivary  11   serum  2   both  1  Blood pressure  7  Heart rate variability  6  Respiratory rate  4  Core body temperature  4  Interleukin (IL)-6  3  Serum inflammatory markers  3  Serum coagulation factors  3  Serum norepinephrine  2  Salivary alpha amylase  2  Serum glucose  2  Subjective measures  Number of studies  State-Trait Anxiety Inventory  4  Fatigue/Sleepiness Scalesa  4  Perceived stressfulness of task  4  Depression Scalesb  3  Chronic Job strain Scalesc  3  Perceived physical exertion of task  2  Smith Relaxation States Inventory 3  2  Bold values were meant to serve as a category header with subcategories. aMaastricht Vital Exhaustion Questionnaire, Samn-Perelli Fatigue Scale, and sleepiness using a visual analogue scale (used twice) bHospital Anxiety & Depression Scale (used twice) & Beck’s Depression Inventory cEffort Reward Imbalance & Overcommitment Questionnaire (used twice) & Karasek’s Job Content Questionnaire View Large Table 2 Summary of objective and subjective measures employed in at least two studies Physiological measures  Number of studies  Heart rate  15  Cortisol  14   salivary  11   serum  2   both  1  Blood pressure  7  Heart rate variability  6  Respiratory rate  4  Core body temperature  4  Interleukin (IL)-6  3  Serum inflammatory markers  3  Serum coagulation factors  3  Serum norepinephrine  2  Salivary alpha amylase  2  Serum glucose  2  Subjective measures  Number of studies  State-Trait Anxiety Inventory  4  Fatigue/Sleepiness Scalesa  4  Perceived stressfulness of task  4  Depression Scalesb  3  Chronic Job strain Scalesc  3  Perceived physical exertion of task  2  Smith Relaxation States Inventory 3  2  Physiological measures  Number of studies  Heart rate  15  Cortisol  14   salivary  11   serum  2   both  1  Blood pressure  7  Heart rate variability  6  Respiratory rate  4  Core body temperature  4  Interleukin (IL)-6  3  Serum inflammatory markers  3  Serum coagulation factors  3  Serum norepinephrine  2  Salivary alpha amylase  2  Serum glucose  2  Subjective measures  Number of studies  State-Trait Anxiety Inventory  4  Fatigue/Sleepiness Scalesa  4  Perceived stressfulness of task  4  Depression Scalesb  3  Chronic Job strain Scalesc  3  Perceived physical exertion of task  2  Smith Relaxation States Inventory 3  2  Bold values were meant to serve as a category header with subcategories. aMaastricht Vital Exhaustion Questionnaire, Samn-Perelli Fatigue Scale, and sleepiness using a visual analogue scale (used twice) bHospital Anxiety & Depression Scale (used twice) & Beck’s Depression Inventory cEffort Reward Imbalance & Overcommitment Questionnaire (used twice) & Karasek’s Job Content Questionnaire View Large We found a wide variety of methodology and occupations represented using our search criteria. We will discuss common subjective and objective measures as well as unique measures from the studies identified. We will highlight the subsequent impact of acute stress on performance of task if reported by study authors. Subjective measures Three studies did not collect or did not report subjective results from study participants beyond basic demographics [31–33]. The State Trait Anxiety Inventory (STAI) emerged as the single most commonly employed measure appearing in four of the studies [27, 28, 34, 35]. Assessment of fatigue or sleepiness in participants was recorded in four studies using three different scales [27–29, 36]. Assessing perceived levels of stress related to the stress-inducing task was also done in four studies [37–40]. The use of two different depression scales in three studies was to illustrate the potential influence of chronic health symptoms on acute stress responses [36, 37, 41]. Chronic job strain was assessed with three different scales to also demonstrate its influence on physiological responses within teachers and nursing professionals [37, 41, 42]. Perceptions of physical exertion were collected in simulation studies using soldiers and firefighters as participants [43, 44]. The Smith Relaxation States Inventory 3 was collected before and after participants engaged in a biofeedback intervention to assess changes in relaxation states [27, 28]. One article assessing acute stress in orchestra musicians used a Work Ability Index (WAI) to characterize study participants and the self-assessment Manikin (SAM) to record affective states [45]. Additional subjective measures found in only one study included: Symptom Checklist-90 to record psychological parameters [42], Surgery Task Load Index (Surg-TLX) to assess workload of a surgeon at designated periods during a surgical procedure [46], and the Big 5 Personality Scale [39]. Objective measures Heart rate and cortisol were the most commonly employed measures with both appearing in more than half of the studies [27–30, 35, 37–39, 41–47]. There was a wider range of objective measures collected, with many only appearing in one study. Electromyography allowed for skeletal muscle activity to be recorded in office workers during a psychomotor computerized task [35]. The rate pressure product was also calculated in this study to ascertain the myocardial workload of participants. Blood lactate levels and assessment of the Critical Flicker Fusion Threshold looked for before and after physiological differences in soldiers engaged in an urban combat simulation [43]. Changes in these measures were related to physical exertion and cortical arousal, respectively. In the study of orchestra musicians, two measures of oxidative stress were used to assess their relationship with pro-inflammatory markers that were also being collected from participants [45]. Conversely, anti-inflammatory markers were used to explore the relationship between psychological state and physiological responses in firefighters after multiple days of simulated fire suppression [29]. Salivary testosterone levels in male police officers examined its role in risky decision making [31]. Finally, adrenocorticotropic hormone (ACTH) was an additional marker for hypothalamic-pituitary-adrenal axis regulation in teachers undergoing an acute psychosocial task [37]. Performance impairment Only five studies reported the impact of acute stress on the quality of performance from participants in study results. Akinola et al. [31] reported a heightened cortisol reactivity was associated with fewer errors (i.e., better performance) to armed targets in a shoot/don’t shoot computerized simulation. Hunziker et al. [40] found high levels of perceived stressfulness of the task by participants resulted in a longer duration to the start of cardiopulmonary resuscitation (CPR) during a simulated patient code. The authors also found a statistically significant positive association between changes in HRV and start time of CPR, with increases in HRV leading to a greater amount of time before beginning CPR. Prinsloo et al. [27] identified differences between the control and experimental group were found after a biofeedback intervention. The group that received the intervention made zero mistakes and had a decrease in reaction time from pre- to postintervention in a computerized task. Regehr et al. [34] found the only physiological parameter significantly correlated with performance measures were cortisol levels at 20 min postsimulation. Self-reports of performance quality from participants showed significant differences in individuals who ranked themselves as performing poorly, when in fact their performance quality received high ranks by the simulation evaluators. The “under assessors” were also noted to be better at maintaining control and taking precautions during the simulation to guarantee safety by the evaluators. Yao et al. [39] found that a higher stress response, defined as an increase in HR, was correlated with increased posterror adjustments in police cadets experiencing acute stress. In this review, we identified and summarized the measures used to explore acute stress in working professionals over the last 10 years. We found trends across the various occupational categories and discovered that some measures were only used in a single article. It is clear that assessing both subjective and objective measures reveals a more powerful interpretation of study results (e.g., [34]). A few studies provided evidence that physiological responses to acute stress could be associated with impairments in performance or enhance performance outcomes. In order to apply these findings to healthcare providers, special consideration is needed to ensure scientific investigations or interventions lead to the greatest benefits at both the individual and team level. DISCUSSION Overall, our results showed that peer-reviewed studies examining acute stress responses in real-world work settings were limited. We will examine our results within the context of our research questions: (i) what are the commonly employed measures, both subjective and objective, investigators use to record acute changes in physiology related to acute stress and (ii) how does acute stress impair performance in defined occupations. We will explore both the research and the pragmatic implications for this literature review with emphasis on the healthcare sector. Healthcare is a profession in which acute stress is common and appropriate stress responses are necessary. Therefore, the higher order concepts acute stress research from other industries are applied directly to healthcare to better understand the implications of acute stress management. In the five studies examining the performance of participants, a post hoc evaluation of performance was utilized [27, 31, 34, 39, 40]. While this is helpful, it may not maximize learning opportunities, because individuals may not immediately be aware when they are beginning to experience performance decrement. In the healthcare setting, any lapses in judgment or poor decisions can have consequences even for the most experienced professional. Because of the potential impact of the stress contagion phenomenon, healthcare centered research needs to focus on preventing the off target effects associated with acute stress rather than waiting to treat them. Second, many of the studies incorporated measures that would be disruptive to the normal workflow of healthcare providers. For example, it is practically difficult for providers to respond to a survey, collect cortisol swabs at designated intervals, or provide patient care with a peripheral intravenous catheter in place. Further gaps in the literature we identified can be categorized into research implications and pragmatic implications. Research implications Study design Although most of the studies in this review incorporated some element of a real-world setting, either in a simulation design or through use of an actual work-related event as the stress-inducing task, seven of the studies did not [27, 28, 32, 33, 35, 40, 48]. The use of naturalistic settings, versus a traditional laboratory setting, could enhance the meaning and implications of physiological responses to acute stress, particularly in healthcare providers. Simulation represents an opportunity for experiential learning that can sculpt the underlying mental model behind the targeted behavior and outcomes [49], at no risk to patients [50]. Working professionals could be conditioned to the experience of a positive performance in a setting that held meaning to their respective occupations. Another important study design consideration is ensuring participants are appropriately recruited and allocated into experimental conditions for physiological performance measurement. For example, gender differences in the physiological response pattern can lead to challenges when interpreting study results. Differences may be revealed based on the stress-inducing task, for example, males on average have a higher cortisol response compared to females when the Trier Social Stress Test (TSST) is used to induce acute psychosocial stress [51]. Gender also plays a role in cytokine expression, such as interleukin-6 (IL-6) [52], a measure incorporated into three of the studies in this review [34, 36, 43]. In this review, 14 of the studies used participants of both genders [29, 31–36, 38, 40, 41, 43, 45–47] and one study did not specify the gender of its only participant [46]. Methodological considerations In the measures recorded, many of the studies used HR to measure acute physiological changes. Accurate recordings of HR in relation to a stress-inducing task can be difficult due to natural fluctuations associated with the respiration cycle, known as the respiratory sinus arrhythmia [53]. To strengthen study findings, researchers should consider calculating HRV from HR recordings as a measure of cardiac vagal tone as was done in six of the studies [27–29, 36, 38, 41]. HRV can be an especially valuable measure when attempting to infer the psychological meaning of a physiological response by serving as the interface between the mind and body [54]. As the study by Yao et al. [39] demonstrated, a higher autonomic stress response was related to increased posterror adjustment during the acute stress task. Differences in the recruitment of cognitive resources, particularly executive versus nonexecutive functions, may have allowed participants to cope with the demands imposed by the task more effectively [55]. Based on the studies reviewed, anticipation of the breakdown in cognitive function is important for consideration in the design of future studies. Tasks meant to induce acute stress and engage executive functions should be designed to alternate between tasks that do not to ensure participants are remaining consistently attentive to the task at hand. In one study, the participants’ low self-rating of performance did not match the high ratings given by an objective evaluator [34]. These results illustrate the benefit of incorporating both subjective and objective measures into the methodology. Correlating subjective reports from participants to objective measures may be beneficial in increasing self-awareness and therefore performance in work settings across multiple disciplines. Administering self-reports post-stress-inducing task could also confirm participants felt a state of stress and prevent habituation in participants. Pragmatic implications Healthcare is a high risk, high stress industry that is unrivaled in its complexity, yet amenable to purposeful research approaches [56]. The use of noninvasive physiological recordings to report changes in real-time could reveal a more robust relationship between acute stress and performance quality. Providers could learn to self-identify negative physiological changes to trigger a positive reappraisal of acutely stressful encounters, with subsequent positive changes in physiology. Real-time measures could also provide confirmation that a change in participants’ physiological response was reflective of a more effective performance mode [16]. The ability to target specific moments of high stress may lead to the development of interventions that are precisely tailored to a physiological response to provide aid in exceptionally detrimental scenarios. Healthcare work requires individuals to work as a team, an important consideration when exploring acute stress. Effective performance of team members can promote a sense of well-being and respect amongst staff and a culture of safety within the organization, leading to improvements in patient outcomes and increased overall satisfaction of healthcare providers [57]. Acute stress management as a coping strategy should be considered a skill that needs to be taught and practiced by all healthcare providers [58]. We identified few intervention studies in this review. However, the use of biofeedback as an intervention to reduce the negative effects of acute stress is promising. As seen in two studies from this review, this intervention only took 10 min and produced statistically significant changes in physiology, subjective measures, and performance in the participants that received the intervention compared to the control group [27, 28]. Limitations There are several limitations are worth noting in this review. Specifically, the limited number of articles that studied healthcare professionals makes generalizability of study results to this field difficult, but also speaks to the paucity of literature available. Our database selection and inclusion criteria were a conscious decision by the authors to enhance the interdisciplinary nature of the methods employed to study acute stress. We wanted to ensure our results reflected the dynamic nature of the acute stress response and felt that limiting inclusion criteria to only healthcare professionals was too narrow in scope. Our inclusion criteria of peer-reviewed journals excluded publications considered gray literature. We felt this was necessary because we were looking at physiological responses to acute stress which requires a high level of expertise to conduct rigorous assessments, the same level of approval found in peer-reviewed journals. Our focus of a well-defined occupation led primarily to single occupational studies which may also limit generalizability. However, we were able to identify common findings and methods across multiple industries. In addition, acute stress and physiological measurement of acute stress are not isolated to a single industry. Examining findings from other industries is important for rapid learning and implementation of interventions. Our search terms could have potentially missed eligible articles from all of the databases, but were selected in order to target acute stress versus chronic stress. We also acknowledge there are many mediators of the acute stress response, such as personality and years of experience, which is beyond the scope of this review. CONCLUSIONS Acute stress can potentially impact performance in the workplace. Objective measures found in the literature to investigate rapid changes in physiology related to acute stress included HR and cortisol. Subjective measures included the STAI, scales to record perceptions of fatigue or sleepiness, and anecdotal perceptions of stressfulness of the discrete task. Impairments to performance under acute stress were mixed. Two studies showed how increased physiological reactivity to stimuli improved performance. Two other studies showed the importance of a participants’ perception and the different outcomes in performance quality. Finally, one studied showed how effective acute stress management interventions are in improving performance. Further empirical research is needed to optimize the performance of healthcare professionals in situations of acute stress. Future research can incorporate methodology that is sensitive and specific to the acute stress response without risk to patients and minimal effort from participants. Proactive, evidence-based interventions cued to acute changes in physiology could prevent performance decrement during stressful events. The ability for healthcare providers to recognize acute stress responses through noninvasive passive measurement tools holds great promise for the performance of current and future employees. SUPPLEMENTARY MATERIAL Supplementary material is available at Translational Behavioral Medicine online. Acknowledgments We confirm that the manuscript has been read and approved by both authors and that there are no other persons who satisfied the criteria for authorship. We acknowledge Whitney DeLong for reviewing article titles and abstracts during the screening process and Rita McCandless for assistance with database search terms. Funding: This study was funded in part by the Agency for Healthcare Research and Quality (grant number R18HS023465-01, Parker PI). Compliance with Ethical Standards We the authors report this is an original manuscript and the findings have not been previously published nor is the manuscript being simultaneously submitted elsewhere. The authors have not previously reported the data. We the authors have full control of all primary data and agree to allow the journal to review data if requested. We declare no conflicts of interest. Per the guidelines of the Declaration of Helsinki, our manuscript did not require an ethics committee review. We state no harm occurred to humans or animals during the preparation of the manuscript. Informed consent was not required to be obtained. IRB approval was also not required for preparation of the manuscript. We further confirm that no aspect of the work covered in this manuscript of a systematic review involved experimental animals or human patients. Authors’ contributions: SEF: Conception and design of review, acquisition of articles, analysis and interpretation of data, and drafting of article. SHP: Confirmed eligibility of articles, provided critical revisions to drafts for intellectual content, ensured integrity of work, and had final approval of the published version. References 1. Bliese PD, Edwards JR, Sonnentag S. Stress and well-being at work: a century of empirical trends reflecting theoretical and societal influences. J Appl Psychol . 2017; 102( 3): 389– 402. 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Measurement of physiological responses to acute stress in multiple occupations: A systematic review and implications for front line healthcare providers

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Abstract

Abstract Optimizing performance of individuals in acutely stressful work-related situations requires a deeper understanding of the interaction between the demands of the stimuli and an individual’s associated physiological response. Identifying these responses is particularly germane for healthcare professionals, who experience episodes of acute stress on a regular basis. The purpose of this review was to examine and synthesize empirical literature to identify studies assessing physiological responses to acute stress, determine common methods for measuring acute stress in near real-time, and identify common research designs employed across industries. A modified PRISMA approach was followed. Systematic searches were conducted of four databases (PsycINFO, Medline, PubMed, and Turning Research into Practice [TRIP]) to access eligibility. Reference list searches and a hand search were also conducted to identify other articles suitable for inclusion. Studies selected examined an acute physiological response while participants were engaged in a stress-inducing task. Twenty-two articles were included. Fifteen (68.2%) were centered on the human service industry while only three (13.6%) focused on healthcare professionals. Half of the studies incorporated a simulation into the research design while only two (9.1%) articles looked at physiological responses in real-world settings. Heart rate and cortisol emerged as the most common physiological measures collected. This review demonstrates that acute stress is primarily assessed retrospectively, and that there is a pragmatic gap in methodological approach, with many data collection methods inappropriate for the healthcare environment. Future research should capitalize on advancements in sensor technology to passively examine acute stress in healthcare professionals. Implications Practice: Management of the effects of acute stress while actively engaged in work-related tasks may improve the performance of healthcare providers which is directly related to patient care. Policy: This paper can inform organizational leaders on the benefits of supporting acute stress management strategies to promote a sense of health and wellness and a culture of safety. Research: Future research on acute stress in healthcare providers can employ methodology to conduct in situ studies using noninvasive and passive measures to proactively identify negative physiological reactions to acute stress that may lead to performance decrement in the workplace. INTRODUCTION Work stress and human performance The relationship between stress and the work environment has been a topic of study for the last century [1]. Employed adults between 25 and 54 years of age spend almost 9 hr on an average weekday engaging in work or work-related activities, making this topic highly relevant across professions [2]. Occupational stress “arises from demands experienced in the working environment that affect how one functions at work or outside work” [3]. Acute stress, defined by the American Psychological Association (APA) as “demands and pressures of the recent past and anticipated demands and pressures of the near future,” is characterized as a brief, event-based phenomenon [4]. Because of its fleeting nature, acute stress represents an aspect of occupational stress that could be managed with preventative approaches in order to optimize performance of employees across work settings. Present day interpretations of the classic Yerkes-Dodson law state that higher amounts of stress can, to a point, lead to a higher level of performance [5]. If the optimal point is exceeded, in moments of acute stress for example, task performance and decision-making abilities could become impaired followed by a decline in performance quality [6]. This decrement in performance is due in part to the inhibition of executive functions, particularly working memory, which can block an individual experiencing acute stress from recruiting past and present resources to aid in performing at an ideal level [7]. The stress response is known to vary according to the nature of the stressor, perception of the severity of the stressor, and factors inherent to each individual with acute stress representing a shorter duration of the stress response [8]. Because of the dynamic nature of stress, assessing an individual’s response during well-defined episodes of acute stress could be a key method to finding the balance between the detrimental effects of stress and optimal performance. In episodes of acute stress, the cognitive appraisal of the stressor dictates the response to the stressor. For example, a challenge response results when the individual perceives the ability to cope with the demands of the situation whereas a threat response results when situational demands are appraised to surpass the available resources inhibiting the individual to cope with the demands [9]. Threat responses to acute stress could lead to subsequent impairments in performance outcomes. Acute stress in healthcare workers Performance decrement within healthcare providers has significant implications not only for patients, but for the providers themselves. Work demands in the healthcare sector are increasing and becoming more complex with advances in technology, the rising prevalence of chronic diseases, the aging baby boomer population, and the expansion of individuals currently covered under the Affordable Care Act [10–12]. These baseline changes in the day-to-day stress of a healthcare provider could potentially increase the magnitude of acute stress in response to an additional stress-inducing task. Previous literature has investigated concepts of occupational stress within healthcare providers [13, 14] and observable changes indicative of strain have been noted to occur over time [15]. With the relationship between acute stress and performance established, adding the high risks common to a healthcare work setting could substantially compound performance decrement. Because eliminating acute stress is not an appropriate option, training protocols that incorporate acute stress management strategies represent a promising area of research that could be applied to the healthcare sector [16]. In response to the ever-changing demands of their job role, healthcare professionals could potentially learn to mitigate their reactions, and therefore negative consequences, to acutely stressful situations [17]. Reducing negative reactions to stress is desirable because an inappropriate response to acute stress has implications beyond individual cognition; it threatens the performance of an entire team. Previous literature has established that the emotions and behaviors of one person can transfer to another person and unconsciously trigger parallel emotions and behaviors in a phenomenon that is referred to as stress contagion [18, 19]. Therefore, an individual provider reacting negatively to acute stress could affect other members of the healthcare team, creating a cycle of performance decrement. Because delivery of high quality healthcare is dependent on effective teamwork, promoting positive reactions to acute stress could benefit individual providers, their colleagues, and most importantly, patients. Measuring acute stress Stress is a state that cannot be directly observed yet affects performance [5]. Evaluation of an individual’s physiological response while experiencing high mental demands with subsequent inference on performance quality is an established concept [20]. Advancements in sensor technology have broadened the number of physiological measures that can be reliably recorded in an unobtrusive and passive manner. Additionally, these measures can be recorded in real-time and in settings outside of a highly controlled research laboratory [21]. Studying acute stress in the real-world ensures an accurate representation of the stressors experienced in daily work life and provides assurance that the stressors encountered will be meaningful to participants [22]. Monitoring physiological responses in real-time secures the capture of response patterns indicative of acute stress and could reveal proactive starting points for intervening to optimize performance under stress [16]. Real-time monitoring also potentially allows researchers to immediately capture biological responses and impart a degree of exactness in the relationship between stimuli and response [20, 22]. This systematic review aims to identify previous empirical research focused on acute stress in working professionals. The results will be interpreted with an emphasis placed on the implications for the healthcare sector. As healthcare providers are expected to make accurate clinical judgments that lead to improved patient care, it is critical to explore their performance in real-time under acute stress. Our specific research questions included: What are the commonly employed measures, both subjective and objective, to record acute changes in physiology related to acute stress? How does acute stress impair performance in defined occupations? METHODS Study identification To ensure we were examining an acute stress response, we focused on articles that assessed markers of stress in near real-time to a clearly defined stress-inducing task. We were also interested in passive measurement mechanisms, since our goal population for application is healthcare providers, and any employed methodology cannot interfere with patient care. Although not an inclusion criterion, we ensured that each article contained at least one physiological measure associated with acute stress reactivity. Those included heart rate (HR), heart rate variability (HRV), and cortisol [23–25]. We operationalized near real-time in accordance to these three measures such that HR and HRV would be monitored before, during, and after the stress-inducing task. For cortisol responses, assessment no later than 40 min after cessation of task was deemed appropriate to capture peak responses [25]. Systematic searches were conducted in February 2017 on the following electronic databases: PsycINFO, PubMed, Medline, and TRIP (Turning Research into Practice). The TRIP database was selected to expand the number of international journals and publications searched. After extensive browsing in each database and after consultation with a clinical research librarian, the authors created search terms unique to each database in an effort to maximize the number of occupations represented in the search results. Additionally, Medical Subject Headings (MeSH) were used for our search within PubMed and Medline to assist with refining our search results. Full electronic search strategies can be found in Supplementary Material 1. Study selection Inclusion criteria for articles were: (i) published in the English language, in a peer-reviewed journal, (ii) specified as containing a physiological measure, (iii) measure was reflective of acute stress, (iv) occupation of participants was clearly stated (i.e., not students), (v) human subjects, adult age groups, (vi) and written within the timeframe of January 1, 2007 to January 31, 2017. We only searched articles from the past 10 years in an effort to review articles that would reflect technological advancements in the field of passive physiological monitoring. Exclusion criteria included: undergraduate students, broadly defined subject groups, only subjective reports of stress from participants, interventions that require specialized credentials (e.g., prescription drugs), patients as participants, and documented diagnoses in participants that could alter stress response (i.e., depression, anxiety, and post-traumatic stress disorder). Between the four databases, 482 articles were identified with our search terms. After duplicate articles were removed, 448 records remained. All 448 titles and abstracts were independently assessed by two reviewers (S.E.F. and a novice second reviewer) for eligibility to reduce bias in the selection process. Any disagreements were discussed and resolved until a consensus was reached; 40 abstracts were found to meet our inclusion criteria. The collection of articles was further reduced to a total of 15 once the full-text of the articles was reviewed. A third reviewer (S.H.P.) independently reviewed all 15 articles and confirmed eligibility. We analyzed the reference sections of these articles and performed hand searching to find an additional seven articles that met inclusion criteria to increase the number of articles included to 22 in total. Data extraction We presumed study participants worked full-time (30 plus hours per week) in the stated occupations unless otherwise noted. The first author of one study was contacted via e-mail to clarify study results. The principal summary measure was a change in baseline physiological measures in the context of responding to a discrete stress-inducing task. Additional key characteristics from each study were identified by the authors prior to database searches. These items were extracted from each study and compiled into a structured spreadsheet (see Supplementary Material 2). Whenever applicable, the process used in this review followed the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) Statement to reduce bias and improve the quality of reporting [26]. We modified the PRISMA approach by not assessing the risk of bias across studies or reporting outcomes related to interventions within the studies as these points were unrelated to the research questions. RESULTS The screening process is summarized using the PRISMA diagram (see Fig. 1). An overview of study characteristics can be found in Table 1. Table 1 Overview of 22 articles assessing acute stress in defined occupations Characteristics  Number of studies (%)  Occupational Category  Human Services  15 (68.2)   Firefighters  7   Police officers  4   Teachers  3   Soldiers  1  Healthcare  3 (13.6)   Residents  1   Nurses and Nursing Assistants  1   Surgeon  1  White collar  3 (13.6)   Senior office managers  2   Office workers  1  Entertainment  1 (4.5)   Orchestra Musicians  1  Country of Study  United States  9 (40.9)  Europe  7 (31.8)  South Africa  2 (9.1)  Australia  2 (9.1)  China  1 (4.5)  Canada  1 (4.5)  Study Setting  Simulation  11 (50)  Laboratory  7 (31.8)  Real-world  2 (9.1)  Laboratory and Real-world  1 (4.5)  Simulation and Laboratory  1 (4.5)  Gender of Participants  Males and Females  14 (63.6)  All males  6 (27.3)  All females  1 (4.5)  Unknown  1 (4.5)  Characteristics  Number of studies (%)  Occupational Category  Human Services  15 (68.2)   Firefighters  7   Police officers  4   Teachers  3   Soldiers  1  Healthcare  3 (13.6)   Residents  1   Nurses and Nursing Assistants  1   Surgeon  1  White collar  3 (13.6)   Senior office managers  2   Office workers  1  Entertainment  1 (4.5)   Orchestra Musicians  1  Country of Study  United States  9 (40.9)  Europe  7 (31.8)  South Africa  2 (9.1)  Australia  2 (9.1)  China  1 (4.5)  Canada  1 (4.5)  Study Setting  Simulation  11 (50)  Laboratory  7 (31.8)  Real-world  2 (9.1)  Laboratory and Real-world  1 (4.5)  Simulation and Laboratory  1 (4.5)  Gender of Participants  Males and Females  14 (63.6)  All males  6 (27.3)  All females  1 (4.5)  Unknown  1 (4.5)  View Large Table 1 Overview of 22 articles assessing acute stress in defined occupations Characteristics  Number of studies (%)  Occupational Category  Human Services  15 (68.2)   Firefighters  7   Police officers  4   Teachers  3   Soldiers  1  Healthcare  3 (13.6)   Residents  1   Nurses and Nursing Assistants  1   Surgeon  1  White collar  3 (13.6)   Senior office managers  2   Office workers  1  Entertainment  1 (4.5)   Orchestra Musicians  1  Country of Study  United States  9 (40.9)  Europe  7 (31.8)  South Africa  2 (9.1)  Australia  2 (9.1)  China  1 (4.5)  Canada  1 (4.5)  Study Setting  Simulation  11 (50)  Laboratory  7 (31.8)  Real-world  2 (9.1)  Laboratory and Real-world  1 (4.5)  Simulation and Laboratory  1 (4.5)  Gender of Participants  Males and Females  14 (63.6)  All males  6 (27.3)  All females  1 (4.5)  Unknown  1 (4.5)  Characteristics  Number of studies (%)  Occupational Category  Human Services  15 (68.2)   Firefighters  7   Police officers  4   Teachers  3   Soldiers  1  Healthcare  3 (13.6)   Residents  1   Nurses and Nursing Assistants  1   Surgeon  1  White collar  3 (13.6)   Senior office managers  2   Office workers  1  Entertainment  1 (4.5)   Orchestra Musicians  1  Country of Study  United States  9 (40.9)  Europe  7 (31.8)  South Africa  2 (9.1)  Australia  2 (9.1)  China  1 (4.5)  Canada  1 (4.5)  Study Setting  Simulation  11 (50)  Laboratory  7 (31.8)  Real-world  2 (9.1)  Laboratory and Real-world  1 (4.5)  Simulation and Laboratory  1 (4.5)  Gender of Participants  Males and Females  14 (63.6)  All males  6 (27.3)  All females  1 (4.5)  Unknown  1 (4.5)  View Large Fig. 1 View largeDownload slide PRISMA diagram on systematic review of literature. Fig. 1 View largeDownload slide PRISMA diagram on systematic review of literature. Overview of studies In many of the studies, the authors attempted to approximate a real-world scenario relevant to the designated occupation under study with an added controlled, but still acutely stressful stimuli (e.g., shoot/don’t shoot task in police officers). Studies were primarily conducted in the USA followed by Europe. Simulation was the most common research setting. The majority of the studies used both male and female participants. The sample sizes in the studies ranged from one to 198, with an average sample size of 62 participants. The study with one participant was looking at the impact of surgical procedure type on physiological response and perceived workload changes in a total of 48 surgeries. The single participant design was a conscious decision by the authors to eliminate interpersonal variability, a common challenge in interpreting results of psychophysiological studies. More than half of the studies were centered on the human services industry. Within this category, firefighters were the predominant profession under investigation with a live firefighting simulation as the acute stress-inducing task. Only three articles were focused on the healthcare industry. Two articles were assessing the pre and post effects of an intervention that could be applicable to the healthcare setting, biofeedback [27, 28]. It appears these articles are from the same data collection period but the results were published in two separate articles. In addition, two articles studying firefighters in Australia appear to be from the same data collection [29, 30]. Table 2 summarizes physiological and subjective measures employed in two or more studies. Detailed reporting of characteristics and results for each study can be found in Supplementary Material 2. Table 2 Summary of objective and subjective measures employed in at least two studies Physiological measures  Number of studies  Heart rate  15  Cortisol  14   salivary  11   serum  2   both  1  Blood pressure  7  Heart rate variability  6  Respiratory rate  4  Core body temperature  4  Interleukin (IL)-6  3  Serum inflammatory markers  3  Serum coagulation factors  3  Serum norepinephrine  2  Salivary alpha amylase  2  Serum glucose  2  Subjective measures  Number of studies  State-Trait Anxiety Inventory  4  Fatigue/Sleepiness Scalesa  4  Perceived stressfulness of task  4  Depression Scalesb  3  Chronic Job strain Scalesc  3  Perceived physical exertion of task  2  Smith Relaxation States Inventory 3  2  Physiological measures  Number of studies  Heart rate  15  Cortisol  14   salivary  11   serum  2   both  1  Blood pressure  7  Heart rate variability  6  Respiratory rate  4  Core body temperature  4  Interleukin (IL)-6  3  Serum inflammatory markers  3  Serum coagulation factors  3  Serum norepinephrine  2  Salivary alpha amylase  2  Serum glucose  2  Subjective measures  Number of studies  State-Trait Anxiety Inventory  4  Fatigue/Sleepiness Scalesa  4  Perceived stressfulness of task  4  Depression Scalesb  3  Chronic Job strain Scalesc  3  Perceived physical exertion of task  2  Smith Relaxation States Inventory 3  2  Bold values were meant to serve as a category header with subcategories. aMaastricht Vital Exhaustion Questionnaire, Samn-Perelli Fatigue Scale, and sleepiness using a visual analogue scale (used twice) bHospital Anxiety & Depression Scale (used twice) & Beck’s Depression Inventory cEffort Reward Imbalance & Overcommitment Questionnaire (used twice) & Karasek’s Job Content Questionnaire View Large Table 2 Summary of objective and subjective measures employed in at least two studies Physiological measures  Number of studies  Heart rate  15  Cortisol  14   salivary  11   serum  2   both  1  Blood pressure  7  Heart rate variability  6  Respiratory rate  4  Core body temperature  4  Interleukin (IL)-6  3  Serum inflammatory markers  3  Serum coagulation factors  3  Serum norepinephrine  2  Salivary alpha amylase  2  Serum glucose  2  Subjective measures  Number of studies  State-Trait Anxiety Inventory  4  Fatigue/Sleepiness Scalesa  4  Perceived stressfulness of task  4  Depression Scalesb  3  Chronic Job strain Scalesc  3  Perceived physical exertion of task  2  Smith Relaxation States Inventory 3  2  Physiological measures  Number of studies  Heart rate  15  Cortisol  14   salivary  11   serum  2   both  1  Blood pressure  7  Heart rate variability  6  Respiratory rate  4  Core body temperature  4  Interleukin (IL)-6  3  Serum inflammatory markers  3  Serum coagulation factors  3  Serum norepinephrine  2  Salivary alpha amylase  2  Serum glucose  2  Subjective measures  Number of studies  State-Trait Anxiety Inventory  4  Fatigue/Sleepiness Scalesa  4  Perceived stressfulness of task  4  Depression Scalesb  3  Chronic Job strain Scalesc  3  Perceived physical exertion of task  2  Smith Relaxation States Inventory 3  2  Bold values were meant to serve as a category header with subcategories. aMaastricht Vital Exhaustion Questionnaire, Samn-Perelli Fatigue Scale, and sleepiness using a visual analogue scale (used twice) bHospital Anxiety & Depression Scale (used twice) & Beck’s Depression Inventory cEffort Reward Imbalance & Overcommitment Questionnaire (used twice) & Karasek’s Job Content Questionnaire View Large We found a wide variety of methodology and occupations represented using our search criteria. We will discuss common subjective and objective measures as well as unique measures from the studies identified. We will highlight the subsequent impact of acute stress on performance of task if reported by study authors. Subjective measures Three studies did not collect or did not report subjective results from study participants beyond basic demographics [31–33]. The State Trait Anxiety Inventory (STAI) emerged as the single most commonly employed measure appearing in four of the studies [27, 28, 34, 35]. Assessment of fatigue or sleepiness in participants was recorded in four studies using three different scales [27–29, 36]. Assessing perceived levels of stress related to the stress-inducing task was also done in four studies [37–40]. The use of two different depression scales in three studies was to illustrate the potential influence of chronic health symptoms on acute stress responses [36, 37, 41]. Chronic job strain was assessed with three different scales to also demonstrate its influence on physiological responses within teachers and nursing professionals [37, 41, 42]. Perceptions of physical exertion were collected in simulation studies using soldiers and firefighters as participants [43, 44]. The Smith Relaxation States Inventory 3 was collected before and after participants engaged in a biofeedback intervention to assess changes in relaxation states [27, 28]. One article assessing acute stress in orchestra musicians used a Work Ability Index (WAI) to characterize study participants and the self-assessment Manikin (SAM) to record affective states [45]. Additional subjective measures found in only one study included: Symptom Checklist-90 to record psychological parameters [42], Surgery Task Load Index (Surg-TLX) to assess workload of a surgeon at designated periods during a surgical procedure [46], and the Big 5 Personality Scale [39]. Objective measures Heart rate and cortisol were the most commonly employed measures with both appearing in more than half of the studies [27–30, 35, 37–39, 41–47]. There was a wider range of objective measures collected, with many only appearing in one study. Electromyography allowed for skeletal muscle activity to be recorded in office workers during a psychomotor computerized task [35]. The rate pressure product was also calculated in this study to ascertain the myocardial workload of participants. Blood lactate levels and assessment of the Critical Flicker Fusion Threshold looked for before and after physiological differences in soldiers engaged in an urban combat simulation [43]. Changes in these measures were related to physical exertion and cortical arousal, respectively. In the study of orchestra musicians, two measures of oxidative stress were used to assess their relationship with pro-inflammatory markers that were also being collected from participants [45]. Conversely, anti-inflammatory markers were used to explore the relationship between psychological state and physiological responses in firefighters after multiple days of simulated fire suppression [29]. Salivary testosterone levels in male police officers examined its role in risky decision making [31]. Finally, adrenocorticotropic hormone (ACTH) was an additional marker for hypothalamic-pituitary-adrenal axis regulation in teachers undergoing an acute psychosocial task [37]. Performance impairment Only five studies reported the impact of acute stress on the quality of performance from participants in study results. Akinola et al. [31] reported a heightened cortisol reactivity was associated with fewer errors (i.e., better performance) to armed targets in a shoot/don’t shoot computerized simulation. Hunziker et al. [40] found high levels of perceived stressfulness of the task by participants resulted in a longer duration to the start of cardiopulmonary resuscitation (CPR) during a simulated patient code. The authors also found a statistically significant positive association between changes in HRV and start time of CPR, with increases in HRV leading to a greater amount of time before beginning CPR. Prinsloo et al. [27] identified differences between the control and experimental group were found after a biofeedback intervention. The group that received the intervention made zero mistakes and had a decrease in reaction time from pre- to postintervention in a computerized task. Regehr et al. [34] found the only physiological parameter significantly correlated with performance measures were cortisol levels at 20 min postsimulation. Self-reports of performance quality from participants showed significant differences in individuals who ranked themselves as performing poorly, when in fact their performance quality received high ranks by the simulation evaluators. The “under assessors” were also noted to be better at maintaining control and taking precautions during the simulation to guarantee safety by the evaluators. Yao et al. [39] found that a higher stress response, defined as an increase in HR, was correlated with increased posterror adjustments in police cadets experiencing acute stress. In this review, we identified and summarized the measures used to explore acute stress in working professionals over the last 10 years. We found trends across the various occupational categories and discovered that some measures were only used in a single article. It is clear that assessing both subjective and objective measures reveals a more powerful interpretation of study results (e.g., [34]). A few studies provided evidence that physiological responses to acute stress could be associated with impairments in performance or enhance performance outcomes. In order to apply these findings to healthcare providers, special consideration is needed to ensure scientific investigations or interventions lead to the greatest benefits at both the individual and team level. DISCUSSION Overall, our results showed that peer-reviewed studies examining acute stress responses in real-world work settings were limited. We will examine our results within the context of our research questions: (i) what are the commonly employed measures, both subjective and objective, investigators use to record acute changes in physiology related to acute stress and (ii) how does acute stress impair performance in defined occupations. We will explore both the research and the pragmatic implications for this literature review with emphasis on the healthcare sector. Healthcare is a profession in which acute stress is common and appropriate stress responses are necessary. Therefore, the higher order concepts acute stress research from other industries are applied directly to healthcare to better understand the implications of acute stress management. In the five studies examining the performance of participants, a post hoc evaluation of performance was utilized [27, 31, 34, 39, 40]. While this is helpful, it may not maximize learning opportunities, because individuals may not immediately be aware when they are beginning to experience performance decrement. In the healthcare setting, any lapses in judgment or poor decisions can have consequences even for the most experienced professional. Because of the potential impact of the stress contagion phenomenon, healthcare centered research needs to focus on preventing the off target effects associated with acute stress rather than waiting to treat them. Second, many of the studies incorporated measures that would be disruptive to the normal workflow of healthcare providers. For example, it is practically difficult for providers to respond to a survey, collect cortisol swabs at designated intervals, or provide patient care with a peripheral intravenous catheter in place. Further gaps in the literature we identified can be categorized into research implications and pragmatic implications. Research implications Study design Although most of the studies in this review incorporated some element of a real-world setting, either in a simulation design or through use of an actual work-related event as the stress-inducing task, seven of the studies did not [27, 28, 32, 33, 35, 40, 48]. The use of naturalistic settings, versus a traditional laboratory setting, could enhance the meaning and implications of physiological responses to acute stress, particularly in healthcare providers. Simulation represents an opportunity for experiential learning that can sculpt the underlying mental model behind the targeted behavior and outcomes [49], at no risk to patients [50]. Working professionals could be conditioned to the experience of a positive performance in a setting that held meaning to their respective occupations. Another important study design consideration is ensuring participants are appropriately recruited and allocated into experimental conditions for physiological performance measurement. For example, gender differences in the physiological response pattern can lead to challenges when interpreting study results. Differences may be revealed based on the stress-inducing task, for example, males on average have a higher cortisol response compared to females when the Trier Social Stress Test (TSST) is used to induce acute psychosocial stress [51]. Gender also plays a role in cytokine expression, such as interleukin-6 (IL-6) [52], a measure incorporated into three of the studies in this review [34, 36, 43]. In this review, 14 of the studies used participants of both genders [29, 31–36, 38, 40, 41, 43, 45–47] and one study did not specify the gender of its only participant [46]. Methodological considerations In the measures recorded, many of the studies used HR to measure acute physiological changes. Accurate recordings of HR in relation to a stress-inducing task can be difficult due to natural fluctuations associated with the respiration cycle, known as the respiratory sinus arrhythmia [53]. To strengthen study findings, researchers should consider calculating HRV from HR recordings as a measure of cardiac vagal tone as was done in six of the studies [27–29, 36, 38, 41]. HRV can be an especially valuable measure when attempting to infer the psychological meaning of a physiological response by serving as the interface between the mind and body [54]. As the study by Yao et al. [39] demonstrated, a higher autonomic stress response was related to increased posterror adjustment during the acute stress task. Differences in the recruitment of cognitive resources, particularly executive versus nonexecutive functions, may have allowed participants to cope with the demands imposed by the task more effectively [55]. Based on the studies reviewed, anticipation of the breakdown in cognitive function is important for consideration in the design of future studies. Tasks meant to induce acute stress and engage executive functions should be designed to alternate between tasks that do not to ensure participants are remaining consistently attentive to the task at hand. In one study, the participants’ low self-rating of performance did not match the high ratings given by an objective evaluator [34]. These results illustrate the benefit of incorporating both subjective and objective measures into the methodology. Correlating subjective reports from participants to objective measures may be beneficial in increasing self-awareness and therefore performance in work settings across multiple disciplines. Administering self-reports post-stress-inducing task could also confirm participants felt a state of stress and prevent habituation in participants. Pragmatic implications Healthcare is a high risk, high stress industry that is unrivaled in its complexity, yet amenable to purposeful research approaches [56]. The use of noninvasive physiological recordings to report changes in real-time could reveal a more robust relationship between acute stress and performance quality. Providers could learn to self-identify negative physiological changes to trigger a positive reappraisal of acutely stressful encounters, with subsequent positive changes in physiology. Real-time measures could also provide confirmation that a change in participants’ physiological response was reflective of a more effective performance mode [16]. The ability to target specific moments of high stress may lead to the development of interventions that are precisely tailored to a physiological response to provide aid in exceptionally detrimental scenarios. Healthcare work requires individuals to work as a team, an important consideration when exploring acute stress. Effective performance of team members can promote a sense of well-being and respect amongst staff and a culture of safety within the organization, leading to improvements in patient outcomes and increased overall satisfaction of healthcare providers [57]. Acute stress management as a coping strategy should be considered a skill that needs to be taught and practiced by all healthcare providers [58]. We identified few intervention studies in this review. However, the use of biofeedback as an intervention to reduce the negative effects of acute stress is promising. As seen in two studies from this review, this intervention only took 10 min and produced statistically significant changes in physiology, subjective measures, and performance in the participants that received the intervention compared to the control group [27, 28]. Limitations There are several limitations are worth noting in this review. Specifically, the limited number of articles that studied healthcare professionals makes generalizability of study results to this field difficult, but also speaks to the paucity of literature available. Our database selection and inclusion criteria were a conscious decision by the authors to enhance the interdisciplinary nature of the methods employed to study acute stress. We wanted to ensure our results reflected the dynamic nature of the acute stress response and felt that limiting inclusion criteria to only healthcare professionals was too narrow in scope. Our inclusion criteria of peer-reviewed journals excluded publications considered gray literature. We felt this was necessary because we were looking at physiological responses to acute stress which requires a high level of expertise to conduct rigorous assessments, the same level of approval found in peer-reviewed journals. Our focus of a well-defined occupation led primarily to single occupational studies which may also limit generalizability. However, we were able to identify common findings and methods across multiple industries. In addition, acute stress and physiological measurement of acute stress are not isolated to a single industry. Examining findings from other industries is important for rapid learning and implementation of interventions. Our search terms could have potentially missed eligible articles from all of the databases, but were selected in order to target acute stress versus chronic stress. We also acknowledge there are many mediators of the acute stress response, such as personality and years of experience, which is beyond the scope of this review. CONCLUSIONS Acute stress can potentially impact performance in the workplace. Objective measures found in the literature to investigate rapid changes in physiology related to acute stress included HR and cortisol. Subjective measures included the STAI, scales to record perceptions of fatigue or sleepiness, and anecdotal perceptions of stressfulness of the discrete task. Impairments to performance under acute stress were mixed. Two studies showed how increased physiological reactivity to stimuli improved performance. Two other studies showed the importance of a participants’ perception and the different outcomes in performance quality. Finally, one studied showed how effective acute stress management interventions are in improving performance. Further empirical research is needed to optimize the performance of healthcare professionals in situations of acute stress. Future research can incorporate methodology that is sensitive and specific to the acute stress response without risk to patients and minimal effort from participants. Proactive, evidence-based interventions cued to acute changes in physiology could prevent performance decrement during stressful events. The ability for healthcare providers to recognize acute stress responses through noninvasive passive measurement tools holds great promise for the performance of current and future employees. SUPPLEMENTARY MATERIAL Supplementary material is available at Translational Behavioral Medicine online. Acknowledgments We confirm that the manuscript has been read and approved by both authors and that there are no other persons who satisfied the criteria for authorship. We acknowledge Whitney DeLong for reviewing article titles and abstracts during the screening process and Rita McCandless for assistance with database search terms. Funding: This study was funded in part by the Agency for Healthcare Research and Quality (grant number R18HS023465-01, Parker PI). Compliance with Ethical Standards We the authors report this is an original manuscript and the findings have not been previously published nor is the manuscript being simultaneously submitted elsewhere. The authors have not previously reported the data. We the authors have full control of all primary data and agree to allow the journal to review data if requested. We declare no conflicts of interest. 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Published: Mar 7, 2018

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