Relationship between three aspects of resilience-adaptive characteristics, withstanding stress, and bouncing back-in hospital workers exposed to prolonged occupational stress during the COVID-19 pandemic: a longitudinal study.

BACKGROUND: The term resilience is used to refer to multiple related phenomena, including: (i) characteristics that promote adaptation to stressful circumstances, (ii) withstanding stress, and (iii) bouncing back quickly. There is little evidence to understand how these components of resilience are related to one another. Skills-based adaptive characteristics that can respond to training (as opposed to personality traits) have been proposed to include living authentically, finding work that aligns with purpose and values, maintaining perspective in the face of adversity, managing stress, interacting cooperatively, staying healthy, and building supportive networks. While these characteristics can be measured at a single time-point, observing responses to stress (withstanding and bouncing back) require multiple, longitudinal observations. This study's aim is to determine the relationship between these three aspects of resilience in hospital workers during the prolonged, severe stress of the COVID-19 pandemic. METHODS: We conducted a longitudinal survey of a cohort of 538 hospital workers at seven time-points between the fall of 2020 and the spring of 2022. The survey included a baseline measurement of skills-based adaptive characteristics and repeated measures of adverse outcomes (burnout, psychological distress, and posttraumatic symptoms). Mixed effects linear regression assessed the relationship between baseline adaptive characteristics and the subsequent course of adverse outcomes. RESULTS: The results showed significant main effects of adaptive characteristics and of time on each adverse outcome (all p < .001). The size of the effect of adaptive characteristics on outcomes was clinically significant. There was no significant relationship between adaptive characteristics and the rate of change of adverse outcomes over time (i.e., no contribution of these characteristics to bouncing back). CONCLUSIONS: We conclude that training aimed at improving adaptive skills may help individuals to withstand prolonged, extreme occupational stress. However, the speed of recovery from the effects of stress depends on other factors, which may be organizational or environmental.

The relationship between moral distress, burnout, and considering leaving a hospital job during the COVID-19 pandemic: a longitudinal survey.

BACKGROUND: Previous research suggests that moral distress contributes to burnout in nurses and other healthcare workers. We hypothesized that burnout both contributed to moral distress and was amplified by moral distress for hospital workers in the COVID-19 pandemic. This study also aimed to test if moral distress was related to considering leaving one's job. METHODS: A cohort of 213 hospital workers completed quarterly surveys at six time-points over fifteen months that included validated measures of three dimensions of professional burnout and moral distress. Moral distress was categorized as minimal, medium, or high. Analyses using linear and ordinal regression models tested the association between burnout and other variables at Time 1 (T1), moral distress at Time 3 (T3), and burnout and considering leaving one's job at Time 6 (T6). RESULTS: Moral distress was highest in nurses. Job type (nurse (co-efficient 1.99, p < .001); other healthcare professional (co-efficient 1.44, p < .001); non-professional staff with close patient contact (reference group)) and burnout-depersonalization (co-efficient 0.32, p < .001) measured at T1 accounted for an estimated 45% of the variance in moral distress at T3. Moral distress at T3 predicted burnout-depersonalization (Beta = 0.34, p < .001) and burnout-emotional exhaustion (Beta = 0.38, p < .008) at T6, and was significantly associated with considering leaving one's job or healthcare. CONCLUSION: Aspects of burnout that were associated with experiencing greater moral distress occurred both prior to and following moral distress, consistent with the hypotheses that burnout both amplifies moral distress and is increased by moral distress. This potential vicious circle, in addition to an association between moral distress and considering leaving one's job, suggests that interventions for moral distress may help mitigate a workforce that is both depleted and burdened with burnout.

The effect of water temperature on orthostatic tolerance: a randomised crossover trial.

PURPOSE: Bolus water drinking, at room temperature, has been shown to improve orthostatic tolerance (OT), probably via sympathetic activation; however, it is not clear whether the temperature of the water bolus modifies the effect on OT or the cardiovascular responses to orthostatic stress. The aim of this study was to assess whether differing water temperature of the water bolus would alter time to presyncope and/or cardiovascular parameters during incremental orthostatic stress. METHODS: Fourteen participants underwent three head-up tilt (HUT) tests with graded lower body negative pressure (LBNP) continued until presyncope. Fifteen minutes prior to each HUT, participants drank a 500 mL bolus of water which was randomised, in single-blind crossover fashion, to either room temperature water (20 °C) (ROOM), ice-cold water (0-3 °C) (COLD) or warm water (45 °C) (WARM). Cardiovascular parameters were monitored continuously. RESULTS: There was no significant difference in OT in the COLD (33 ± 3 min; p = 0.3321) and WARM (32 ± 3 min; p = 0.6764) conditions in comparison to the ROOM condition (31 ± 3 min). During the HUT tests, heart rate and cardiac output were significantly reduced (p < 0.0073), with significantly increased systolic blood pressure, stroke volume, cerebral blood flow velocity and total peripheral resistance (p < 0.0054), in the COLD compared to ROOM conditions. CONCLUSIONS: In healthy controls, bolus cold water drinking results in favourable orthostatic cardiovascular responses during HUT/LBNP without significantly altering OT. Using a cold water bolus may result in additional benefits in patients with orthostatic intolerance above those conferred by bolus water at room temperature (by ameliorating orthostatic tachycardia and enhancing vascular resistance responses). Further research in patients with orthostatic intolerance is warranted.

Exaggerated postural sway improves orthostatic cardiovascular and cerebrovascular control.

Introduction: Healthy individuals with poor cardiovascular control, but who do not experience syncope (fainting), adopt an innate strategy of increased leg movement in the form of postural sway that is thought to counter orthostatic (gravitational) stress on the cardiovascular system. However, the direct effect of sway on cardiovascular hemodynamics and cerebral perfusion is unknown. If sway produces meaningful cardiovascular responses, it could be exploited clinically to prevent an imminent faint. Methods: Twenty healthy adults were instrumented with cardiovascular (finger plethysmography, echocardiography, electrocardiogram) and cerebrovascular (transcranial Doppler) monitoring. Following supine rest, participants performed a baseline stand (BL) on a force platform, followed by three trials of exaggerated sway (anterior-posterior, AP; mediolateral, ML; square, SQ) in a randomized order. Results: All exaggerated postural sway conditions improved systolic arterial pressure (SAP, p = 0.001) responses, while blunting orthostatic reductions in stroke volume (SV, p < 0.01) and cerebral blood flow (CBFv, p < 0.05) compared to BL. Markers of sympathetic activation (power of low-frequency oscillations in SAP, p < 0.001) and maximum transvalvular flow velocity (p < 0.001) were reduced during exaggerated sway conditions. Responses were dose-dependent, with improvements in SAP (p < 0.001), SV (p < 0.001) and CBFv (p = 0.009) all positively correlated with total sway path length. Coherence between postural movements and SAP (p < 0.001), SV (p < 0.001) and CBFv (p = 0.003) also improved during exaggerated sway. Discussion: Exaggerated sway improves cardiovascular and cerebrovascular control and may supplement cardiovascular reflex responses to orthostatic stress. This movement provides a simple means to boost orthostatic cardiovascular control for individuals with syncope, or those with occupations that require prolonged motionless standing.

Adult attachment insecurity and responses to prolonged severe occupational stress in hospital workers during the COVID-19 pandemic.

Background: The stress response includes appraisal of the threat and one's resources, coping (including interpersonal interactions), distress, and recovery. Relationships between patterns of adult attachment and stress response have received little study in the context of prolonged, severe occupational stress, limiting knowledge about how attachment patterns contribute to occupational burnout and recovery. Aim: This study aimed to assess the relationship of adult attachment to aspects of the stress response over time in hospital workers during a pandemic. Methods: This study included 538 hospital workers within a general and a rehabilitation hospital in Toronto, Canada between September 2020 and November 2021. Half, selected at random, completed validated measures of adult attachment, resilience, self-efficacy, coping, interpersonal problems, and various stress outcomes. Attachment insecurity severity was calculated as the vector addition of attachment anxiety and attachment avoidance. Correlations between these measures were determined at individual time-points and temporal patterns of adverse outcomes using repeated-measures ANOVA. Results: All correlations between measures of attachment and resilience or self-efficacy were significant and moderately strong (r = .30-.48), while most correlations with coping strategies were weak (<.20). Attachment avoidance was more strongly correlated with interpersonal problems related to being cold, whereas attachment anxiety was more strongly correlated with problems related to being intrusive, overly-nurturant, exploitable and non-assertive. Attachment insecurity severity was moderately correlated with every dimension of interpersonal problems. A significant main effect of each attachment measure on each stress outcome was found (effects sizes: .18-.26). Attachment insecurity severity was significantly associated with outcome X time interactions for burnout, consistent with greater resilience for those with lower attachment insecurity. Conclusions: Severity of insecure attachment was correlated with each measure of self-appraisal, interpersonal problems, and all measured stress outcomes. Severity of attachment insecurity performed well as a summary attachment measure. Greater security is associated with patterns of recovery that indicate resilience.

Evaluating the Impact of Orthostatic Syncope and Presyncope on Quality of Life: A Systematic Review and Meta-Analysis.

PURPOSE: Syncope (transient loss of consciousness and postural tone) and presyncope are common manifestations of autonomic dysfunction that are usually triggered by orthostasis. The global impact of syncope on quality of life (QoL) is unclear. In this systematic review, we report evidence on the impact of syncope and presyncope on QoL and QoL domains, identify key factors influencing QoL in patients with syncopal disorders, and combine available data to compare QoL between syncopal disorders and to population normative data. METHODS: A comprehensive literature search of academic databases (MEDLINE (PubMed), Web of Science, CINAHL, PsycINFO, and Embase) was conducted (February 2021) to identify peer-reviewed publications that evaluated the impact of vasovagal syncope (VVS), postural orthostatic tachycardia syndrome (POTS), or orthostatic hypotension (OH) on QoL. Two team members independently screened records for inclusion and extracted data relevant to the study objectives. RESULTS: From 12,258 unique records identified by the search, 36 studies met the inclusion criteria (VVS: n = 20; POTS: n = 13; VVS and POTS: n = 1; OH: n = 2); 12 distinct QoL instruments were used. Comparisons of QoL scores between patients with syncope/presyncope and a control group were performed in 16 studies; significant QoL impairments in patients with syncope/presyncope were observed in all studies. Increased syncopal event frequency, increased autonomic symptom severity, and the presence of mental health disorders and/or comorbidities were associated with lower QoL scores. CONCLUSION: This review synthesizes the negative impact of syncope/presyncope on QoL and identifies research priorities to reduce the burden of these debilitating disorders and improve patient QoL.

Trends in burnout and psychological distress in hospital staff over 12 months of the COVID-19 pandemic: a prospective longitudinal survey.

BACKGROUND: The mental health effects of healthcare work during the COVID-19 pandemic have been substantial, but it is not known how long they will persist. This study aimed to determine if hospital workers' burnout and psychological distress increased monotonically over 1 year, during which waves of case numbers and hospitalizations waxed and waned, or followed some other pattern. METHODS: A prospective longitudinal survey was conducted at four time-points over 1 year in a cohort of 538 hospital workers and learners, which included validated measures of burnout (emotional exhaustion scale of Maslach Burnout Inventory) and psychological distress (K6). Repeated measures ANOVA tested changes over time and differences between subjects by occupational role, age and ethnic group. The direction and magnitude of changes over time were investigated by plotting rates of high scores (using cut-offs) at each time-point compared to case rates of COVID-19 in the city in which the study took place. RESULTS: There were significant effects of occupational role (F = 11.2, p < .001) and age (F = 12.8, p < .001) on emotional exhaustion. The rate of high burnout was highest in nurses, followed by other healthcare professionals, other clinical staff, and lowest in non-clinical staff. Peak rates of high burnout occurred at the second or third measurement point for each occupational group, with lower rates at the fourth measurement point. Similarly to the results for emotional exhaustion, rates of high psychological distress peaked at the spring 2021 measurement point for most occupational groups and were higher in nurses than in other healthcare professionals. CONCLUSIONS: Neither emotional exhaustion nor psychological distress was rising monotonically. Burnout and psychological distress were consistently related to occupational role and were highest in nurses. Although emotional exhaustion improved as the case rate of COVID-19 decreased, rates of high emotional exhaustion in nurses and other healthcare professionals remained higher than was typically measured in hospital-based healthcare workers prior to the pandemic. Ongoing monitoring of healthcare workers' mental health is warranted. Organizational and individual interventions to support healthcare workers continue to be important.

Psychological impact of the COVID-19 pandemic on hospital workers over time: Relationship to occupational role, living with children and elders, and modifiable factors.

OBJECTIVE: The COVID-19 pandemic is expected to have a sustained psychological impact on healthcare workers. We assessed individual characteristics related to changes in emotional exhaustion and psychological distress over time. METHODS: A survey of diverse hospital staff measured emotional exhaustion (Maslach Burnout Inventory) and psychological distress (K6) in Fall 2020 (T1) and Winter 2021 (T2). Relationships between occupational, personal, and psychological variables were assessed using repeated measures ANOVA. RESULTS: Of 539 T1 participants, 484 (89.9%) completed T2. Emotional exhaustion differed by occupational role (F = 7.3, p < .001; greatest in nurses), with increases over time in those with children (F = 8.5, p = .004) or elders (F = 4.0, p = .047). Psychological distress was inversely related to pandemic self-efficacy (F = 110.0, p < .001), with increases over time in those with children (F = 7.0, p = .008). Severe emotional exhaustion occurred in 41.1% (95%CI 36.6-45.4) at T1 and 49.8% (95%CI 45.4-54.2) at T2 (McNemar test p < .001). Psychological distress occurred in 9.7% (95%CI 7.1-12.2) at T1 and 11.6% (95%CI 8.8-14.4) at T2 (McNemar test p = .33). CONCLUSIONS: Healthcare workers' psychological burden is high and rising as the pandemic persists. Ongoing support is warranted, especially for nurses and those with children and elders at home. Modifiable protective factors, restorative sleep and self-efficacy, merit special attention.

Pubertal Hormonal Changes and the Autonomic Nervous System: Potential Role in Pediatric Orthostatic Intolerance.

Puberty is initiated by hormonal changes in the adolescent body that trigger physical and behavioral changes to reach adult maturation. As these changes occur, some adolescents experience concerning pubertal symptoms that are associated with dysfunction of the autonomic nervous system (ANS). Vasovagal syncope (VVS) and Postural Orthostatic Tachycardia Syndrome (POTS) are common disorders of the ANS associated with puberty that are related to orthostatic intolerance and share similar symptoms. Compared to young males, young females have decreased orthostatic tolerance and a higher incidence of VVS and POTS. As puberty is linked to changes in specific sex and non-sex hormones, and hormonal therapy sometimes improves orthostatic symptoms in female VVS patients, it is possible that pubertal hormones play a role in the increased susceptibility of young females to autonomic dysfunction. The purpose of this paper is to review the key hormonal changes associated with female puberty, their effects on the ANS, and their potential role in predisposing some adolescent females to cardiovascular autonomic dysfunctions such as VVS and POTS. Increases in pubertal hormones such as estrogen, thyroid hormones, growth hormone, insulin, and insulin-like growth factor-1 promote vasodilatation and decrease blood volume. This may be exacerbated by higher levels of progesterone, which suppresses catecholamine secretion and sympathetic outflow. Abnormal heart rate increases in POTS patients may be exacerbated by pubertal increases in leptin, insulin, and thyroid hormones acting to increase sympathetic nervous system activity and/or catecholamine levels. Given the coincidental timing of female pubertal hormone surges and adolescent onset of VVS and POTS in young women, coupled with the known roles of these hormones in modulating cardiovascular homeostasis, it is likely that female pubertal hormones play a role in predisposing females to VVS and POTS during puberty. Further research is necessary to confirm the effects of female pubertal hormones on autonomic function, and their role in pubertal autonomic disorders such as VVS and POTS, in order to inform the treatment and management of these debilitating disorders.

Validation of finger blood pressure monitoring in children.

BACKGROUND: Continuous beat-to-beat blood pressure monitoring permits the rapid detection of blood pressure fluctuations for cardiovascular reflex testing and clinical haemodynamic monitoring. In adults, this can be achieved noninvasively with high accuracy, using finger blood pressure monitoring with volume clamp photoplethysmography. However, data are lacking on the validity of finger blood pressure monitoring in children compared to the gold standard - invasive intra-arterial blood pressure monitoring. AIM: We aimed to evaluate the accuracy of novel noninvasive index and middle finger arterial pressure (FinAP) measurements in children. METHODS: Using prototype paediatric finger cuffs, we compared: mean differences, bias and limits of agreement (Bland-Altman analyses); cumulative percentage differences [clinical grade A-D (based on the percentage of heartbeats in agreement with the standard)]; and waveform morphology (regression analysis and smoothing) between both raw FinAP (Finapres NOVA) and reconstructed finger-brachial arterial pressure (reBAP) compared to intra-arterial blood pressure measurements. RESULTS: Eighteen children were tested (aged 3-13 years; 12 male), with data from 13 included in the analysis. The bias for reBAP for the middle finger was 1.8±6.9, 0.3±6.1 and 0.4±5.3 mmHg for systolic, diastolic and mean arterial pressure, with clinical grades of C, B and A, respectively. reBAP improved numerical accuracy, but reduced waveform morphological agreement. CONCLUSION: Middle finger arterial measurements with waveform reconstruction provide an acceptable surrogate for invasive intra-arterial recording in children. Finger blood pressure monitoring is a novel comfortable, convenient and accurate alternative approach for noninvasive beat-to-beat blood pressure monitoring in children.