Assessing Nurse Learners' Stress Using Technology to Measure Physiologic Adaptation Within Interprofessional Patient Care Simulation

Friday, 28 July 2017

Jill Van Der Like, DNP, MSN
School of Nursing, University of West Florida, Pensacola, FL, USA
Lela Hobby-Burns, DNP, MSN, APHN-BC
University of West Florida; School of Nursing; College of Health, University of West Florida, Pensacola, FL, USA
Eric Greska, PhD
Department of Exercise Science and Community Health, University of West Florida, Pensacola, FL, USA


Recent public reports find that communication-based errors contribute to medical errors as the third leading cause of death in America (Fikes, 2016; Kaiser Health News, 2016). Safe, efficient reporting of patient information is perplexing, especially for newly graduated nursing staff. Communication skills cannot develop through memorization and knowledge, but, rather, through practice and experience during the education process (Goh, 2016). Interprofessional communication is pivotal for patient safety as nurses accumulate patient information and transfer the important facts to physicians, psychologists, pharmacists, dietitians, social workers, technicians and other key team members. The Simulation (SIM) laboratory provides a safe, realistic setting for learners to become familiar with accommodating their stress while practicing teamwork and communication skills.

Nurses frequently report job dissatisfaction related to the stressful work environment. Current turnover rates among nursing staff are approaching 15%, which has led to a focus on retention strategies (AACN, 2016). Newly graduated nurses especially feel overwhelmed about a lack of team support when building their practice competencies (AACN, 2016; IOM, 2011). Simulation Interprofessional education (SIM-IPE) practice during the undergraduate learning process builds confidence in team communication, knowledge, and skills (AACN, 2016; Ruebling et al., 2014). SIM-IPE is an effective teaching strategy that facilitates learning while building confidence and reducing anxiety. During SIM-IPE, learners from multiple disciplines role-play decision-making to communicate vital information among team members. These SIM-IPE learning experiences promote familiarity with the complex roles and responsibilities among the healthcare team. New graduates use these foundational team skills from their first day and on as a member of the healthcare team.

The autonomic nervous system (ANS) regulates vital involuntary functions of the body. The system is divided into sympathetic nervous system (i.e., heart rate acceleration, blood vessel constriction, increase in blood pressure) and the parasympathetic nervous system (i.e., slows the heart rate, increases intestinal and gland activity and relaxes sphincter muscles). Current technology can measure the ANS response and indicate stress adaptation.


The purpose of this descriptive longitudinal study is to examine nurse learners’ biological stress adaptation during SIM-IPE experiences. These adaptation indicators were monitored 8 times as learners (n=57) progressed through their first semester, and 31 times the second semester as junior-year Bachelor of Science in Nursing (BSN) students.

During the simulation sessions, students were fitted with a Bioharness (Medtronic, Annapolis, MD) physiologic module to monitor heart rate variability (HRV). Post-processing of the HRV data utilized KubiosHRV software (version 2.2, Kuopio, Finland) to assess the frequency domains during simulation participation and peer-to-peer debriefing sessions. The high-frequency domain is relative to parasympathic (vagus) response, whereas the low-frequency domain measures a combination of parasympathetic and sympathetic (i.e., parasympathetic when respiration is below 7 bpm, otherwise sympathetic).

Sample and Setting

In the United States, the setting is a School of Nursing in a Florida mid-sized public university. The University’s Nursing and Exercise Science faculty collaborated on SIM-IPE design and data collection. The nurse faculty conducted the SIM-IPE laboratory experiences, while the Exercise Science faculty set up, monitored and analyzed the data collected. SIM-IPE learners were informed of the research study details, and signed a university-approved IRB consent before participating. A convenience sample of junior-year nurse learners (n=57) was selected in a prelicensure Bachelor of Science in Nursing (BSN) program. The SIM-IPE experience occurred in the nursing school’s SIM laboratory, debriefing room, and Home Hospice SIM room. Learners were assigned one (1) of three (3) roles primary nurse, secondary nurse, and resource nurse. The primary nurse leads the care decisions with secondary nurse assisting, while resource nurse communicates important patient information to the team. Each participant completed 5 SIM-IPE experiences over 2 semesters, and the roles were randomly rotated per student volunteers. The nurse instructor briefed the learners with a nurse report of important patient information prior to care.

Data Collection

During the SIM-IPE briefing, Exercise Science faculty fitted learners with a Zephyr BioHarness™3 sensor that was worn next to learners' skin beneath their uniform shirt. This technology senses and records the physiologic indicators of stress (i.e., heart rate, heart rate variability, respiration rate, and trunk inclination level). The Zephyr BioHarness™3 sensor continuously monitors the learner’s activity throughout the SIM experience and instructor’s debriefing period. Exercise Science faculty monitored and used a time-stamp marker to define the learner’s stress indicators during simulated patient care and debriefing. Learners’ roles were carefully identified and recorded so faculty could analyze the real-time changes in stress adaptation. The data is automatically recorded and stored into a password protected laptop, and backed up by a university lab password protected intranet.


The Zephyr BioHarness™3 sensor measured physiological stress indicators during each SIM nurse role and debriefing. Data was analyzed collectively to determine when stress adaptation were more prevalent. Findings revealed that during the semester’s initial SIM-IPE sessions, nurse learners demonstrated an increase in stress indicators while involved in patient care activities. However, over time and after five (5) SIMs, stress indicators were lower, indicating learners adapted to stress, and, perhaps more confident when performing the patient care activities (i.e., sensor data demonstrated an increase in high-frequency relative power, with an equivalent reduction in the low-frequency relative power from the beginning to the end of the semester). This change in heart rate variability frequency bands demonstrates a change in neural influence from sympathetic to more parasympathetic controls, thus indicating stress adaptation. Learners, as the semester progressed, appeared to adapt to stress during SIM patient care activities. However, during all the post-SIM debriefing peer-analysis sessions, throughout both semesters, learners' physiologic stress indicators remained high.
Analysis of these debriefing sessions finds these same learners displayed no changes in their frequency relative power, indicating that stress, brought on by peer-to-peer accountability, still remained high. Learners' stress levels remained high, unchanged, when explaining their patient care and decision-making.


Conclusion: The IOM (2011) states that interprofessional collaboration and coordination should be the norm for quality patient care. This study supports the SIM-IPE environment as a safe learning environment to reduce stress and promote teamwork. The SIM-IPE environment provides nurse learners practice to adapt to the stress of patient care, and perhaps indicates more confidence of their patient care skills and interactions. However, these same learners continue to have unchanged stress adaptation levels during the peer-to-peer debriefing session.
More research is needed on learners' stress adaptation during peer-to-peer debriefing. SIM-IPE should be integrated across the learning continuum, where learners build knowledge, skills and positive attitudes across practice settings and professions (IPEC, 2011).