Kunal Khanade

Stress, fatigue, and workload in intensive care nursing: A scoping literature review

Stress and fatigue are being interchangeably used in the nursing literature resulting in operationalization and measurement issues. A scoping review was conducted to identify different definitions and operationalization of these constructs. Findings can be used to develop tools to measure stress and fatigue as different constructs to aid nursing administrators to gain a new perspective into nursing schedule, workload, morale and well-being of nurses. The findings show that there is a research gap in measurement of acute stress in nursing, physiological measures are currently not used for continuous assessment of stress or fatigue for nurses, and lack of stress and fatigue definitions in terms of physiological measures for assessment purposes. Continuous monitoring and physiological measures such as heart rate can be used to measure and differentiate between the constructs of stress and fatigue

Passenger-Driver Distinguishing Test for Pokémon Go

Distracted driving while gaming is a serious hazard especially for young drivers. Increasing popularity of augmented reality games may increase distracted driving incidents. The main purpose of this study is to test the feasibility of an identification test to differentiate between drivers and passengers to prevent drivers from playing augmented reality games while driving to reduce distracted driving incidents. We hypothesized that increased cognitive burden will reduce vigilance on the secondary task which will reduce attention and increase the risk associated with the secondary task. An experiment with a driving simulator tested university students’ performance to evaluate the efficacy of the distinguishing test. The results show that the test shows promise to distinguish between drivers and passengers. Such tests can be used in applications when users perform two tasks that require the same modality leading to decreased performance in both tasks.

Heart Rate Assessment for Posttraumatic Stress Disorder Symptoms among Military Veterans: A Narrative Literature Review

Post-Traumatic Stress Disorder (PTSD) is a psychiatric condition affecting as much as 20% of the returning veterans from the current wars in Afghanistan and Iraq (Ramchand et al., 2010). Due to its prevalence, assessment and intervention methods for PTSD symptoms among veterans are timely to ensure veterans’ faster recovery and their reintegration into society. A narrative review of literature was conducted to examine the literature on techniques and methods for detection and measurement of PTSD symptoms. Relevant reviews and seminal papers associated with psychophysiological measurements with emphasis on heart rate, the prevalence of PTSD in military veterans, and detection of PTSD were included. Psychophysiology involves the non-invasive recording of biological processes simultaneously (Pole, 2007). The measures that were found to be reliably related to PTSD are: (1) higher resting heart rate; (2) larger heart rate responses to standardized trauma cues; and (3) for idiographic cues facial muscle electromyography (EMG) and heart rate responses (Pole, 2007). Studies based on heart rate found that there were five beats per minute (bpm) increase in resting heart rates for combat veterans who suffer from PTSD compared to those who were not diagnosed (Beckham et al., 2000, Woodward et al., 2009). Buckley et al. (2004) found that for a mixed population (veterans and civilians) PTSD patients had a resting heart rate increase of 6.6 bpm compared to non-PTSD patients while adjusting for covariates. The exact mechanisms of how stress affects heart rate are not well-known; however, it is possible to observe stressful events and relate these to physiological changes in heart rate that can be measured using modern sensors (Andreoli et al., 2010). In the literature, heart rate is analyzed using statistical, geometric, frequency domain, time-frequency and non-linear feature analysis (Acharya et al., 2006). Non-linear features have been developed to quantify the dynamics of heart rate fluctuations. These include approximate entropy, Detrended Fluctuation Analysis (DFA), Lyapunov exponent, Recurrence Plots (RPs) and Correlation Dimension (CD) (Pincus, 1991; Huikuri et al., 2000; Acharya et al., 2004; Acharya et al., 2006). Our synthesis resulted in identification of three research gaps. Heart rate analysis has shown promise to link PTSD symptoms to differences in PTSD and non-PTSD subjects (Pole, 2007) but a characterization of PTSD symptoms from heart rate data seems to remain a research gap. While continuous monitoring of physiological parameters is gaining momentum, this particular method has not been studied to infer key characteristics associated with PTSD among military veterans. Continuous monitoring might be able to highlight muted response to startle or treatment. There is also a research gap in the assessment of heart rate accelerations and decelerations in response to specific PTSD symptoms (Khanade et al., 2017). The investigation into accelerations/decelerations associated with PTSD hyper-arousal triggers might have a potential to detect hyper-arousal instantaneously and would shed light on trigger-specific interventions to reduce harmful effects of PTSD triggers in a timely manner. In addition, most studies were conducted to observe differences among PTSD and non-PTSD populations. More work is warranted to focus on PTSD patients in isolation to explain variety of triggers and their specific physiological reactions.

Investigating Architectural and Space Design Considerations for Post-Traumatic Stress Disorder (PTSD) Patients

Post-Traumatic Stress Disorder (PTSD) is a prevalent condition among the general U.S. population but in particular for veterans. Anecdotal evidence points to the effect of urban design features on mental well-being of PTSD patients. However, evidence-based architectural and space design guidelines for PTSD patients is largely absent. Such guidelines might alleviate PTSD symptoms and improve patients’ quality of life. Interviews were conducted with combat veterans who were diagnosed with PTSD (sub population focus) to gain insights into their thoughts, needs, expectations, and experiences with physical indoor and out-door spaces. The findings suggest that certain indoor and outdoor design elements such as sharp corners, narrow pathways, blind spots, etc. increase anxiety and leads to triggers while soothing features (e.g. open spaces, situational awareness providing features such as lack of clutter or open floor plans) can relax veterans.

Stress Detection Techniques in Different Work Domains

Nurses represent a large portion of shift workers in United States. Nurses often work long hours, have high workload, and usually participate in multitasking, all of which may lead to high stress, turnover, and burn-out. The turnover rate among nurses tends to be higher than other healthcare professions. Some studies have analyzed the nursing culture to determine the factors that lead to such high turnover and stress. How-ever, most of the studies have relied on self-reported instruments. While objective metrics to assess stress using physiological measures exist, these methods are rarely used in healthcare. The current study documents the findings from a literature review of stress detection techniques in other work domains (e.g., aviation, transportation). Stress detection techniques are explained, along with potential applications to the healthcare sector.

Design of a Wearable Stress Monitoring Tool for Intensive Care Unit Nursing: Functional Information Requirements Analysis

Nurses are the last line of defense to reduce preventable medical errors; however, they suffer from poor systems design and human factors issues (e.g., long shifts, dynamic workload, stressful situations, and fatigue), contributing to a reduced quality of care. A smart nursing system based on physiological monitoring is being designed to help nurses and their managers to efficiently communicate, reduce interruptions that affect critical task performance, and monitor acute stress and fatigue levels. This paper documents the systematic process of deriving information requirements through a group-participatory usability study, conducted with nurses working in various Southeastern Texas hospitals. Information requirements derived from these studies include: a need for accessing patients’ vital signs as well as laboratory results, memory aid tools for various critical nursing tasks, and options to call for help and to reduce interruptions for critical tasks. The system shows promise to meet these requirements.

Veteran-centered Design of a Post-Traumatic Stress Disorder (PTSD) Tool: Qualitative Analysis of Interviews with Veterans

Many veterans from recent wars are suffering from Post-Traumatic Stress Disorder (PTSD). PTSD is a mental health disorder or an anxiety-based psychiatric condition developed after witnessing or living through distressing events along with feelings of fear, helplessness and horror. Technological interventions have been discussed as viable treatment alternatives in the recent literature (Henderson, Davis, Smith, & King, 2014; Majerowicz & Tracy, 2010), but only a few have been validated using formal human factors and usability engineering methods, and integration into clinicians’ work remains an overall gap (Rodriguez-Paras et al., 2017). The overall scarcity of literature on PTSD-supportive technologies or tools can be traced back to the complexity of PTSD care and lack of a systems perspective and user-centered design approaches. With a combination of coordinated and ad hoc efforts to meet the demands, the current PTSD care system has naturally evolved into a highly complex socio-technical system with multiple stakeholders. To design a tool to fit in the existing care system, it is imperative to first address the system’s complexity from the perspectives of both end-users, i.e., healthcare providers and veterans with PTSD. The lack of systems perspective in currently available tools, which could lead to a loss of potential opportunities for improvement, is partly due to the absence of clear understanding of the current PTSD care system for veterans to inform the design of such tools (Moon, Smith, Sasangohar, Benzer, & Kum, 2017). As an initial effort to address such a research gap, this paper investigates veterans’ perspectives on improvement areas in the current PTSD care system and how these areas can be addressed with potential technologies or tools. Findings from recent interviews with clinicians suggest that the current system lacks consideration of the unique characteristics of veterans with PTSD and lacks treatment control in-between sessions (Moon et al., 2017). Building on these findings, this research aims at (1) understanding the unique behavioral and attitudinal characteristics of veterans with PTSD, (2) identifying improvement opportunities in overall PTSD care processes or pathways (especially in-between sessions), and (3) deriving functional requirements for PTSD treatment-supportive technologies or tools. This paper documents our findings from an iterative qualitative data analysis (QDA) of iterative semi-structured interviews with 20 veterans diagnosed with PTSD. The interviews were transcribed, coded, and analyzed by two coders using MAXQDA-12, using the general thematic analysis approach containing three phases of sense-making which seek to refine themes and model relationships among interviewee responses (Bryman, 2015; Corbin & Strauss, 2015): initial coding, focused coding, and modeling relationships. A highlight of findings is presented as emerging topics pertaining to our three aims. (1) To be compatible with veteran world-outlooks and daily lives, design solutions must understand their unique behaviors or attitudes. Three topics emerged as follows: Topic 1: Social Isolation. Topic 2: Avoid/Leave Situation. Topic 3: Breathe and Calm (Refocus). (2) Interviews led to some holistic observations regarding opportunities in the “overall PTSD care process”. Findings can be categorized into two groups: those pertaining to a veteran’s regular psychotherapy appointment (i.e. “treatment”), and those during times and places between these appointments; and two topics: Topic 4: Disconnect from the Therapist. Topic 5: Hyperarousal Triggers. Findings suggest hyperarousal triggers inhibit quality of life by encouraging avoidance, high perceived value of welltimed alerts, and a need for closing a disconnect between clinicians and their patients. (3) Veteran feedback was used to explore functional requirements for potential PTSD treatmentsupportive technologies or tools. The word “functional” demonstrates our pursuit of an objective assessment that reveals “solution-neutral” functions, thereby informing design decisions about how systems or solutions can fulfill these functions. The following topics represent veteran responses to direct inquiries about what functions may be useful in a supportive technology: Topic 6: Warn/Intervene for Hyperarousal Onset. Topic 7: Peer-to-Peer (P2P) Connection. Topic 8: Clinician Support Function. Findings will inform the design of supportive solutions to connect patients to peers, report crucial information to clinicians between sessions, and leverage breathing or meditation exercises to encourage healthy refocus. The QDA topics synthesize veteran responses to interview questions and offer some valuable insight into their lives. Also, the exploration of behaviors and attitudes through modeling relationships between their responses allows creative insights to emerge, e.g., potential avenues for follow-up questions or refreshing new perspectives. This opens the design space beyond the boundaries of our requests for direct feedback. Findings are expected to inform the process of designing novel PTSD treatment-supportive technologies and enable them to be better integrated with the current care system. While the findings documented in this paper contribute to further understanding how to design solutions for those veterans afflicted with PTSD, future work must go towards exploring how these insights can be operationalized and evaluated.

Stress and Fatigue in ICU Nursing

Intensive care is a complex system wherein stress and fatigue can increase the likelihood of medical errors. Approximately 85,000 errors occur in US Intensive Care Units (ICU) in a day (Donchin et al., 1995; Wu et al., 2002). Studies show nurses are stressed and fatigued while working in this complex error prone environment. In one research, estimated 60% of ICU nurses reported medium to high levels of stress (Guerrer & Bianchi, 2011) while approximately 65% reported fatigue during work hours in critical care (Scott et al., 2006). One of the difficulties with reducing ill effects of stress and fatigue in ICU is the lack of operationalizable definitions for these constructs and issues in measurement. Selye (1956) defined stress as an unspecific response of the body to any demand that might be internal or external in nature. Since then, stress has been generally defined in terms of a set of stressors such as unnecessary prolongation of life, conflict with physicians and unrealistic expectations from colleagues, self, and patient families. Nursing stress in literature is classified into two fields, organizational stress and stress related to patient care. Organizational stressors include lack of clear responsibilities and authorities, performing unnecessary tasks, and lack of a trained team for transferring patients to other hospitals. Stress related to patient care includes the difference in capacity of wards and number of patients, as well as training students and new staff (Bahadori et al., 2014). Chronic stress leads to burnout among nurses and results in high turnover rates in the nursing profession. Burnout can also lead to lower morale, reduced job performance, higher tardiness, absenteeism, high turnover rate, and alcohol and drug abuse. Another unique stressor for the nursing profession is moral distress. Moral distress is defined as the lack of freedom to act in a moral way. Chronic stress elicits a response that is usually unfavorable to an individual’s well-being. The construct of nursing ‘workload’ has been documented as a stressor. Morris et al. (2007) referred to the term nursing work as, “the amount of work performance required to carry out nursing work in a specified time.” According to Duffield et al. (2006), an excessive workload is linked to stress and dissatisfaction among nurses (Aiken et al 2001; Fagin 2001, in Duffield et al., 2006). An individual’s lack of well-being and degraded work performance may occur when workload moves beyond an acceptable level resulting in physiological strain. This can manifest as heart rate elevation or behavior changes such as reduced work pace (Chen et al., 2011). An acceptable workload definition was provided by Wu & Wang (2001) as a level that an individual is able to sustain for a given work shift in a physiologically steady state without fatigue or discomfort. An excessive workload for nurses leads to lack of rest between tasks, which in turns leads to fatigue. Fatigue is defined in a variety of ways in different domains. Fatigue can be defined as “a general psychophysiological phenomenon that diminishes the ability of the individual to perform a particular task by altering alertness and vigilance, together with the motivational and subjective states that occur during this transition.” (Thiffault & Bergeron, 2003, in De Vries et al., 2003). Fatigue is also associated with lack of recovery period where lack of rest acts as a stressor. Distinguishing unique factors associated with stress or fatigue, particularly chronic aspects of these constructs, is challenging in ICU nursing. The constructs of stress and fatigue influence nursing activities and can lead to degraded performance like medical errors. Other effects include higher turnover rates, unnecessary costs, loss of productivity and increase in healthcare costs. There is a research gap in the identification of acute stress and fatigue thresholds above which there is a risk to individual’s well-being in ICU nursing. This gap in measurement if left unchecked can lead to chronic diseases, increased medical errors because of memory lapses or slips and other off-work incidents like drowsy driving. Continuous monitoring of effects of stress and fatigue on physiological parameters shows promise to measure and mitigate ill effects of these constructs. A variety of measurement techniques are used in literature to measure stress and fatigue in an ICU setting. Some overlap and measure effects of both stress and fatigue. Physiological measures are used in research studies to look at an isolated construct such as stress in ICU nurses; however, these biometric measures show effects of both stress and fatigue making it difficult to identify effects due to a single construct. Because it is difficult to separate the effects of the constructs of stress and fatigue from one another in an ICU setting, the feasibility of a combined construct can be considered to investigate degraded performance. The effects of both stress and fatigue can be combined as one entity labeled as ‘psychophysical health deterioration’ in ICU nurses. It will be easier to study combined effects instead of performing studies investigating a single construct in isolation.

Efficacy of Using Heart Rate Measurements as an Indicator to Monitor Anxiety Disorders: A Scoping Literature Review

Post-traumatic stress disorder (PTSD) is a prevalent disorder affecting veterans, first responders, children and others who have experienced traumatic events. Heart rate measures like resting heart rates along with heart rate accelerations are important measures to monitor the changes in the state of PTSD and other related disorders. A scoping review was conducted to investigate the efficacy of using heart rate (HR) measurements as reliable indicator for assessment of PTSD and other anxiety-related disorders. Findings show that while Heart Rate Variability (HRV) may provide a more robust measurement of PTSD and other anxiety-related symptoms, heart rate accelerations in response to traumatic reminders are reliable indicators. Changes in resting or basal heart rates show promise in long-term monitoring of PTSD symptoms.