The effects of stress-anxiety and coping styles on heart rate variability.

This study explored the effects of a naturally occurring stressor on the amplitudes of the respiratory sinus arrhythmia and Traube-Hering-Mayer bands of the power spectra of cardiac interbeat intervals of 15 Highly Anxious, 15 Truly Low Anxious and 15 Repressor women. Interbeat interval samples were obtained from 4.5 min tachygraph records while the subjects sat quietly 2 weeks before (2W), the day before (DB) and 1 week following (WA) their oral comprehensive examinations. Subjects also reported their state anxiety on each occasion. Repeated measures ANOVA indicated that subjects' state anxiety was greater on the DB than on the other two occasions. Heart rates were faster for the DB than for the 2W and WA occasions. Truly Low Anxious women had slower heart rates, across all occasions, than did Repressors or Highly Anxious women. Although respiratory sinus arrhythmia amplitudes did not differ across occasions, RSA amplitudes were smaller for individuals with high trait anxiety (Repressors and Highly Anxious) than for subjects with low trait anxiety (Truly Low Anxious). Traube-Hering-Mayer amplitudes were smaller on the DB than the 2W or WA occasions for all subjects and were smaller for Repressors or Highly Anxious women than for Truly Low Anxious women across occasions.

The conceptually-oriented physician.

This article is based on the authors' book "Physician or Magician: The Myths and Realities of Patient Care" (McGraw Hill and Hemisphere, 1978). In this paper, the authors contend that the main problem confronting medical practice and medical education today is that there is no consensus on what physicians should be doing. Should they be technologists or should they be conceptually-oriented? The authors further state that these two types of physicians are trained in different approaches to problem solving. They conclude by saying that both types of physicians are needed if the quality of patient care is to improve while containing cost, but that the conceptually-oriented physician--the primary physician--should be in charge of all treatment patients receive. This is because the primary physicians as well as the Cartesian approach. Therefore, they would be better able to determine the risks and benefits to each patient of various technological regimens.

Fluctuations in established infant pain behaviors.

This study compares behaviors that differed across levels of established (e.g., nonprocedural) infant pain with those that differed between periods of greater and lesser distress within any level of infant pain. Sixty-four videotaped infants of two ages (0 to 3 months and 7 to 12 months) and four levels of established infant pain (none, mild, moderate, and severe) were used. Pain was from medical or surgical causes. Behaviors were compared between the most distressed (HI) and the least distressed (LO) video segments per infant and across the four levels of infant pain using a two-level (distress and level of pain) MANOVA. Many behaviors were indicative of high levels of established pain and greater distress. Others increased with greater distress but lower levels of pain. Findings suggest that many behaviors indicative of high distress that constitute the immediate infant pain response are not good indicators of levels of established infant pain.

Generalizability and clinical utility of a practice-based infant pain assessment instrument.

The purpose of this study was to determine the clinical usefulness and generalizability of an infant pain assessment instrument. Earlier work showed that this instrument--an algorithm derived from a model of infant pain assessment-possessed excellent content validity, criterion-like validity, and 3-month stability (test-retest reliability). In this study, generalizability was determined by comparing the percentage agreement between inexperienced pediatric nurses and one author, both using the tool to assess pain of infants in various clinical settings, and by comparing the percentage agreement between one author who used the tool to assess pain and the infant's pediatric nurse caretaker who used his or her clinical expertise, not the tool, to assess pain across various clinical settings. The results show excellent generalizability.

Validity and reliability of a practice-based infant pain assessment instrument.

The purpose of this study was to determine the validity and reliability of an infantpain assessment instrument. This instrument is an algorithm derived from a model of infant pain assessment that emerged from interviews with pediatric nurses and includes methods for evaluating clinical data that suggest the Iikelihood of pain. Unlike other instruments, this instrument is not restricted to use in clinical situations where the likelihood of pain is evident. This instrument determines the three levels of pain that guide subsequent nursing interventions: no pain, mild pain (discomfort), and severe pain. Content validity was determined by obtaining and incorporating feedback from a focus group of practicing pediatric nurses on various developmental stages of the instrument. Criterion-like validity was excellent: Mean Pearson correlations between the pain ratings of 18 videotaped infants by 24 nursing students using the instrument with ratings performed by a panel of 5 expert nurses not using any instrument was 0.96. Test-retest reliability, as measured by Pearson correlations between pain ratings 3 months apart, was also excellent (r = 0.91).

The effect of pain on infant behaviors.

Facial, body, and cry behaviors, heart rate, palmar sweating, and acoustic cry measures were compared across differing levels of infant pain. Eighty-eight infants were placed in a 16-cell matrix of 4 ages (0 to 3 mo., 4 to 6 mo., 7 to 9 mo., and 10 to 12 mo.) and levels of pain (LOP) (none, mild, moderate, severe) with 5 to 6 infants occupying each cell. Matrix placement was determined by agreement of > 75% among five pediatric clinical nurse specialists who viewed videotapes and read information about the infant's history, diagnosis, medical and/or surgical status, medications, and nutritional/fluid status. Coded infant behaviors and acoustic cry parameters were compared using a 2-level (LOP, age) MANOVA. Behaviors that differed across LOP were influenced by infant development. Facial expressions were clinically useful LOP indicators only for 0- to 3-month-old infants. Facial and body behaviors and cry measures that differed across LOP in younger infants did not differ in older infants due to the development of intentionality. Cry orientation and consolability may be useful clinical indicators of pain with older infants.

Distribution of cues across assessed levels of infant pain.

A convenience sample of 24 more experienced, 20 less experienced, and 20 novice nurses assessed videotaped infants in varying degrees of pain (none, mild, moderate, and severe), as determined by an expert panel. Participants identified all information they used in making an assessment (All cues) and that subset they deemed most important (Key cues). Data were analyzed using a two-level analysis of variance (level of assessed pain and pediatric nursing experience). Forty-five of the 62 cues mentioned by participants did not differ across levels of pain. Eleven All cues and 11 Key cues differed between infants in pain and not in pain, suggesting that these cues may be potentially useful as predictors of the presence/absence of pain. Three All cues differed both between pain and no pain as well as between levels of pain, which suggests that participants' awareness of subtle leveling might be used in the discrimination of a wider range of pain levels. Differences in cue utilization among the more experienced, less experienced, and novice participants are discussed.

The influence of background clinical data on infant pain assessments.

The purpose of this study was to determine the importance of knowledge of clinical background data on nursing assessments of infant pain. In a quasi-experimental design, the infant pain assessments of two groups of pediatric nurses were compared. Both groups assessed the levels of pain of the same videotaped infants. One group also read clinical background data about each infant; the other group did not. The group who read clinical background data evidenced higher mean levels of assessed pain per videotaped infant than did the group who only viewed the videotapes. Findings underscore the importance of clinical data and clinical context in the process of assessing infant pain and the risk of underestimating pain when all factors are not considered.

Testing a model of the nursing assessment of infant pain.

The purpose of this study was to test whether elements of an infant pain assessment model interacted as postulated by the model. The elements are the infant's response to comfort measures and the principle of consolability. Four different scenarios for each of 16 videotaped infants were prepared. Each scenario represented one of four different combinations of likelihood of pain and consolability and consisted of a videotape plus written clinical information. Forty-eight volunteer pediatric nurses assessed infant pain of 16 scenarios, each depicting one of the 16 infants. Mean level of assessed pain was highest for the "high likelihood of pain and difficult to console" group, second highest for the "high likelihood of pain and easily consoled" group, third highest for the "low likelihood of pain and difficult to console" group and least for the "low likelihood of pain and easily consoled" group. Findings supported the infant pain assessment model.

Acoustic analysis of cries from "normal" and "irritable" infants.

Infant irritability or colic is characterized by recurrent episodes of persistent, unexplained crying. The lack of a precise definition of the type and amount of cry that distinguishes an infant as colicky has hampered research and intervention efforts. The primary aims of this study are to describe the acoustic characteristics of cries of irritable infants and compare these to those of normal infants. Tape recorded cries of 11 irritable and 11 non-irritable infants were compared. The average age for infants of both groups was 8 weeks. The cries of irritable infants were higher in jitter, shimmer, proportion of noise, and tenseness than were the cries of control infants. Findings suggest that colic or infant irritability is more than just excessive crying. Acoustic characteristics of the cries of irritable infants reveal an increase in stress-arousal that supports the thesis of a state regulation disorder. Characterizing the nature and origin of the cries of irritable infants is essential to an understanding that will eventually guide appropriate diagnosis and management of these infants.

Spectral energy distribution in four types of infant vocalizations.

The distribution of spectral energy among four types of infant vocalizations was compared via computerized spectral analyses of "pain-induced," "fussy," and "hungry" cries and "cooing" of 30 2-6-month-old infants. Visual inspection indicated that "pain-induced" cries could be differentiated from "fussy" and "hungry" cries and that "cooing" could be differentiated from all cries on the bases of (1) the relative amplitude levels of the high-frequency components; (2) the average fundamental frequency; and (3) the overall spectral energy levels. Analysis of variance showed that (1) the mean spectral energy (MSE) levels of "pain-induced" cries were significantly higher than those of the other two types of cries and that the MSE of all three types of cries was significantly higher than that of cooing; and (2) that the mean spectral energy in any vocalization by 6-month-old infants of either sex was significantly lower than that in any vocalization of younger infants.

Differences in fundamental frequency, jitter, and shimmer among four types of infant vocalizations.

An inaudible voice variable, known to be influenced by stress-arousal in adults, was recently discovered to differ significantly among four situationally defined types of infant vocalizations. Other research suggests that jitter in adults also may be altered by stress-arousal. Further, there is a lack of normative data on jitter and shimmer in infant vocalizations. These findings prompted this study comparing F0, jitter, and shimmer among four situationally defined vocalizations ("pain," "hunger," "fussy," and "cooing") of 2-6-month-old infants. Data showed no significant difference in either jitter or shimmer among the four vocalizations; no significant difference in F0, jitter, or shimmer due to the sex or age of infant; a significant difference in F0 among "hunger," "cooing," and either "pain" or "fussy" vocalizations; and no significant difference in F0 between "pain" or "fussy" cries.

Selection of vigilant and avoidant coping strategies among repressors, highly anxious and truly low anxious subjects.

70 female graduate students from a western university were classified as to personality type: Highly Anxious, Truly Low Anxious, and Repressing, using a combination of scores from the Taylor Manifest Anxiety Scale and the Marlowe-Crowne Social Desirability Scales. Each subject's preference for monitor or blunter coping strategy was assessed via the Miller Behavioral Style Scale. Highly Anxious subjects chose significantly more monitor strategies than did Truly Low Anxious subjects or Repressors. The number of blunter strategies chosen did not differ across personality types. Chi-squared indicated that Highly Anxious subjects were more often classified as monitors than blunters whereas the proportions of monitors and blunters did not significantly differ between Truly Low Anxious subjects and Repressors. Results suggest that the repressor trait is distinct from avoidant and vigilant coping strategies.

Reliability and validity of an interval measure of vocal stress.

The reliability and validity of Psychological Stress Evaluator (PSE) output and frequency modulation suppression as an inaudible vocal measure of stress-arousal was further explored, using a new interval scoring method. 'Yes' answers to 6 neutral questions were obtained from 106 volunteers 2 weeks before, the day before and one week after a stress-provoking event (oral comprehensive examinations for an MS degree). The data show excellent construct validity and good but not high internal consistency (0.77-0.81) and test-retest (0.72-0.74) reliability. Interrater reliability ranged from 0.94 to 0.98. Correlations of PSE output with other psychological and physiological measures (criterion-related validity) was very poor.

Acoustic discrimination of three types of infant cries.

The ability of acoustic characteristics, both separately and in linear combination with others, to differentiate among procedural pain-induced, hungry, and fussy crying was explored using audiorecordings of cries from healthy 2 to 4-month-old infants. Fussy cries were less tense than hungry or pain-induced cries and pain-induced cries had significantly stronger second formant amplitudes than fussy or hungry cries. Formants and tenseness were important contributors to a linear combination of acoustic measures, derived from discriminant function analysis, which correctly classified 74% of the procedural pain-induced crying specimens. The inability of this linear combination of acoustic measures to identify correctly approximately one-third of the cry specimens suggests that the discrete acoustic differences among the three situationally defined types of crying is not large.