Heart rate variability as a strain indicator for psychological stress in emergency medical services personnel during working days: a systematic review
Beatrice Thielmann1, Linda Voß1, Igor Zavgorodnii2, Heiko Schumann1, Irina Böckelmann1
1Institute of Occupational Medicine, Medical Faculty, Otto-von-Guericke-University, Magdeburg, Leipziger Str. 44, (Building 20), 39120 Magdeburg, Germany
2Department of Hygiene and Ecology No 2, Kharkiv National Medical University, Ukraine
Full article (PDF): ENG
Background: Emergency medical services personnel have highly variable workloads. The resulting stress can differ intra- or inter-individually. Consequences for health arise when there is insufficient compensation for prolonged stress. The analysis of heart rate variability (HRV) is a valid noninvasive method for the objective monitoring of workload in the occupational medicine. The aim of this paper is to systematically evaluate the literature on HRV as an objective indicator of the mental stress faced by emergency medical services personnel.
Methods: A systematic literature review examining the HRV of prehospital emergency medical services personnel in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement for reporting systematic reviews was performed. PubMed, Ovid, Cochrane Library, Scopus, and Web of Science electronic databases were used. Modified STARD for HRV was used to evaluate the methodological quality of HRV measurement. Two authors independently reviewed the papers and performed the evaluations.
Results: The literature search identified 5,637 citations. Four studies were included that investigated HRV during working days compared to nonworking days, but no focus on alert operations. Two studies used Holter ECG, and two used chest belts. Two studies evaluated cardiac autonomic function in the time and frequency domains, and the other two studies used only the time domain. The results showed an adaptation of HRV under working conditions. The studies were not comparable, because the study protocols were different.
Conclusions: There is a need for occupational health studies that examine the strains and stress of emergency medical services personnel, especially under alert interventions. The well-established HRV parameters seem to be suitable for objectively measuring stress. HRV measurement is also suitable for active alert and operation around the patient. Future research should further additionally investigate nonlinear parameters or parameters without clear assignment. Guideline standards should be respected.
Keywords: heart rate variability, workload, mental stress, rescue workers, alarm, rescue.
References
- Aasa U, Kalezic N, Lyskov E, Angquist K-A, Barnekow-Bergkvist M. Stress monitoring of ambulance personnel during work and leisure time. Int Arch Occup Environ Health. 2006;80(1):51-9. DOI: https://doi.org/10.1007/s00420-006-0103-x.
- Afshari A, Borzou SR, Shamsaei F, Mohammadi E, Tapak L. Perceived occupational stressors among emergency medical service providers: a qualitative study. BMC Emergency Medicine. 2021;21(1):35. DOI: https://doi.org/10.1186/s12873-021-00430-6.
- Almutairi I, Al-Rashdi M, Almutairi A. Prevalence and Predictors of Depression, Anxiety and Stress Symptoms in Paramedics at Saudi Red Crescent Authority. Saudi J Med Med Sci. 2020;8(2):105-11. DOI: https://doi.org/10.4103/sjmms.sjmms_227_18.
- Awad G, Pohl R, Darius S, Thielmann B, Varghese S, Wacker M. Schmidt H, Wippermann J, Scherner M, Böckelmann I. Activation of the stress response among the cardiac surgical residents: comparison of teaching procedures and other (daily) medical activities. J Cardiothorac Surg. 2022;17(1):112. DOI: https://doi.org/10.1186/s13019-022-01873-z.
- Bergner T. Belastungen in der Notfallmedizin. Notfall Rettungsmed. 2018;21(3):192-8. DOI: https://doi.org/10.1007/s10049-018-0447-2.
- Blau G, Chapman SA. Why do Emergency Medical Services (EMS) Professionals Leave EMS? Prehosp Disaster Med. 2016;31(S1):S105-S111. DOI: https://doi.org/10.1017/S1049023X16001114.
- Böckelmann I, Seibt R. Methoden zur Indikation vorwiegend psychischer Berufsbelastung und Beanspruchung - Möglichkeiten für die betriebliche Praxis. Z Arbeitswiss. 2011;65(3):205-22. DOI: https://doi.org/10.1007/BF03373839.
- Bossuyt PM, Reitsma JB, Bruns DE, Gatsonis CA, Glasziou PP, Irwig LM, Lijmer JG, Moher D, Rennie D, de Vet HC for the STARD Group. Toward Complete and Accurate Reporting of Studies of Diagnostic Accuracy: The STARD Initiative. Am J Clin Pathol. 2003;119(1):18-22. DOI: https://doi.org/10.1309/8EXCCM6YR1THUBAF.
- Cash RE, Anderson SE, Lancaster KE, Lu B, Rivard MK, Camargo CAJR, Panchal AR. Comparing the Prevalence of Poor Sleep and Stress Metrics in Basic versus Advanced Life Support Emergency Medical Services Personnel. Prehosp Emerg Care. 2020;24(5):644-56. DOI: https://doi.org/10.1080/10903127.2020.1758259.
- Cohen JF, Korevaar DA, Altman DG, Bruns DE, Gatsonis CA, Hooft L, Irwig L, Levine D, Reitsma JB, de Vet HCW, Bossuyt PMM. STARD 2015 guidelines for reporting diagnostic accuracy studies: explanation and elaboration. BMJ Open. 2016;6(11):e012799. DOI: https://doi.org/10.1136/bmjopen-2016-012799.
- Crowe RP, Bower JK, Cash RE, Panchal AR, Rodriguez SA, Olivo-Marston, SE. Association of Burnout with Workforce-Reducing Factors among EMS Professionals. Prehosp Emerg Care. 2018;22(2):229-36. DOI: https://doi.org/10.1080/10903127.2017.1356411.
- Dobbs WC, Fedewa MV, MacDonald HV, Holmes CJ, Cicone ZS, Plews DJ, Esco MR. The Accuracy of Acquiring Heart Rate Variability from Portable Devices: A Systematic Review and Meta-Analysis. Sports Medicine. 2019;49(3):417-35. DOI: https://doi.org/10.1007/s40279-019-01061-5.
- Durand A-C, Bompard C, Sportiello J., Michelet P, Gentile S. Stress and burnout among professionals working in the emergency department in a French university hospital: Prevalence and associated factors. WORK: A Journal of Prevention, Assessment & Rehabilitation. 2019;63(1):57-67. DOI: https://doi.org/10.3233/WOR-192908.
- Grässler B, Thielmann B, Böckelmann I, Hökelmann A. Effects of different training interventions on heart rate variability and cardiovascular health and risk factors in young and middle-aged adults: a systematic review. Front Physiol. 2021;12:532. DOI: https://doi.org/10.3389/fphys.2021.657274.
- Hegg-Deloye S, Brassard P, Jauvin N, Prairie J, Larouche D, Poirier P, Tremblay A, Corbeil P. Current state of knowledge of post-traumatic stress, sleeping problems, obesity and cardiovascular disease in paramedic. Emerg Med J. 2014;31(3):242-7. DOI: https://doi.org/10.1136/emermed-2012-201672.
- Järvelin-Pasanen S, Sinikallio S, Tarvainen MP.Heart rate variability and occupational stress-systematic review. Ind Health. 2018;56(6):500-11. DOI: https://doi.org/10.2486/indhealth.2017-0190.
- Khatiban M, Hosseini S, Bikmoradi A, Roshanaei G, Karampourian A. Occupational Burnout and Its Determinants among Personnel of Emergency Medical Services in Iran. Acta Med Iran. 2015;53(11):711-6.
- Laborde S, Mosley E, Thayer JF. Heart Rate Variability and Cardiac Vagal Tone in Psychophysiological Research - Recommendations for Experiment Planning, Data Analysis and Data Reporting. Front Psychol. 2017;8:213. DOI: https://doi.org/10.3389/fpsyg.2017.00213.
- Mitani S, Fujita M, Shirakawa T. Circadian variation of cardiac autonomic nervous profile is affected in Japanese ambulance men with a working system of 24-h shifts. Int Arch Occup Environ Health. 2006;79(1):27-32. DOI: https://doi.org/10.1007/s00420-005-0026-y.
- Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. J Clin Epidemiol. 2009;62(10):1006-12. DOI: https://doi.org/10.1016/j.jclinepi.2009.06.005.
- Neufeld EV, Carney JJ, Dolezal BA, Boland DM, Cooper CB. Exploratory Study of Heart Rate Variability and Sleep among Emergency Medical Services Shift Workers. Prehosp Emerg Care. 2017;21(1):18-23. DOI: https://doi.org/10.1080/10903127.2016.1194928.
- Patterson PD, Weaver MD, Frank RC, Warner CW, Martin-Gill C, Guyette FX, Fairbanks RJ, Hubble MW, Songer TJ, Callaway CW, Kelsey SF, Hostler D. Association Between Poor Sleep, Fatigue, and Safety Outcomes in Emergency Medical Services Providers. Prehosp Emerg Care. 2012;16(1):86-97. DOI:10.3109/10903127.2011.616261. https://doi.org/10.3109/10903127.2011.616261
- Quintana DS, Alvares GA, Heathers JAJ. Guidelines for Reporting Articles on Psychiatry and Heart rate variability (GRAPH): recommendations to advance research communication. Transl Psychiatry. 2016;6(5):e803-e803. DOI: https://doi.org/10.1038/tp.2016.73.
- Rutter LA, Vahia IV, Passell E, Forester BP, Germine L. The role of intraindividual cognitive variability in posttraumatic stress syndromes and cognitive aging: a literature search and proposed research agenda. Int Psychogeriatr. 2021;33(7):677-87. DOI: https://doi.org/10.1017/S1041610220000228.
- Sammito S, Böckelmann I. Analyse der Herzfrequenzvariabilität. Herz. 2015;40(1):76-84. DOI: https://doi.org/10.1007/s00059-014-4145-7.
- Sammito S, Thielmann B, Seibt R, Klussmann A, Weippert M, Böckelmann I. Guideline for the application of heart rate and heart rate variability in occupational medicine and occupational science. ASU International. 2015. DOI: https://doi.org/10.17147/ASUI.2015-06-09-03.
- Sassi R, Cerutti S, Lombardi F, Malik M, Huikuri HV, Peng C-K, Schmidt G, Yamamoto Y. Advances in heart rate variability signal analysis: joint position statement by the e-Cardiology ESC Working Group and the European Heart Rhythm Association co-endorsed by the Asia Pacific Heart Rhythm Society. Europace. 2015;17(9)1341-53. DOI: https://doi.org/10.1093/europace/euv015.
- Schumann H. Belastungen und Beanspruchungen von Einsatzkräften im Rettungsdienst [dissertation]. Otto-von-Guericke-Universität; 2018.
- Schumann H. Belastungen und Beanspruchungen von Einsatzkräften im Rettungsdienst. Eine vergleichende Analyse zwischen Hilfsorganisationen und Berufsfeuerwehren. Edewecht: Stumpf + Kossendey; 2020.
- Schumann H, Böckelmann I, Thielmann B. Belastungserleben während der Corona-Pandemie-Wellen. Was denken die Einsatzkräfte? Rettungsdienst. 2021;44(8):712-5.
- Shaffer F, Ginsberg JP. An Overview of Heart Rate Variability Metrics and Norms. Front Public Health. 2017;5:258. DOI: https://doi.org/10.3389/fpubh.2017.00258.
- Stein C, Sibanda T. Burnout among paramedic students at a university in Johannesburg South Africa. African Journal of Health Professions Education. 2016;8(2):193-5. DOI: https://doi.org/10.7196/AJHPE.2016.v8i2.626.
- Sterud T, Hem E, Lau B, Ekeberg O. A comparison of general and ambulance specific stressors: predictors of job satisfaction and health problems in a nationwide one-year follow-up study of Norwegian ambulance personnel. J Occup Med Toxicol. 2011;6(1):10. DOI: https://doi.org/10.1186/1745-6673-6-10.
- Task Force of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology. Heart rate variability. Standards of measurement, physiological interpretation, and clinical use. Eur Heart J. 1996;17(3):354-81.
- Thielmann B, Pohl R, Böckelmann I. Heart rate variability as a strain indicator for psychological stress for emergency physicians during work and alert intervention: a systematic review. J Occup Med Toxicol. 2021;16(1):24. DOI: https://doi.org/10.1186/s12995-021-00313-3.
- Vigil NH, Grant AR, Perez O, Blust RN, Chikani V, Vadeboncoeur TF, Spaite DW, Bobrow BJ. Death by Suicide-The EMS Profession Compared to the General Public. Prehosp Emerg Care. 2019;23(3):340-5. DOI: https://doi.org/10.1080/10903127.2018.1514090.
- Wong IS, Ostry AS, Demers PA, Davies HW. Job strain and shift work influences on biomarkers and subclinical heart disease indicators: a pilot study. J Occup Environ Hyg. 2012;9(8):467-77. DOI: https://doi.org/10.1080/15459624.2012.693831.