www.nccosc.navy.mil

Research on Identifying and Managing Occupational Stress in the Military

Jennifer Webb-Murphy, PhDTheodore C. Morrison, PhD, MPH

Research Facilitation DepartmentNaval Center for Combat & Operational Stress Control

Eileen Delaney, PhD

Gabriel De La Rosa, PhD

Steven Gerard, BA

Erin Miggantz, PhD

Scott Roesch, PhD

Martha Sanders, MA

Kurt Vyas, BS, BA

NCCOSC Research Facilitation Department

CAPT Scott Johnston, PhD, Director, NCCOSC

Contributors

The opinions expressed in this article are the author's own and do not necessarily reflect the view of the United States Government, the United States Department of Defense, The United States Navy, or The United States Navy Bureau of Medicine and Surgery. 

The study protocol was approved by the Naval Medical Center San Diego Institutional Review Board in compliance with all applicable Federal regulations governing the protection of human subjects.

I am an employee of the U.S. Government. This work was prepared as part of my official duties. Title 17 U.S.C. §105 provides that ‘copyright protection under this title is not available for any work of the United States Government.’ Title 17 U.S.C §101 defines U.S. Government work as a work prepared by a military service member or employee of the U.S. Government as part of that person’s official duties.

Disclaimer

Increased Stress in the Military• Unique demands of military setting• Increased number of deployments• Longer deployments• Fiscal constraints• Reduced manning• Residual impact of OEF/OIF/OND

Selected Collaborative Research on Military Stress Conducted by NCCOSC

Studies on Identifying Stress1.Provider Wellbeing Study

2.Stress and Resilience in SERE School Instructors

Studies on Managing Stress 3.Coherence Training among Military Personnel

4.Stress Resilience Training System

Study 1: Provider WellbeingCollaborators:

LCDR Paul Sargent, MD, NSW

CDR Jeffrey Millegan, MD, NMCSD, DMH

LT Heather Mak, MD, NMCSD, DMH

Leonard Mallahan, BA, NMCSD, Quality Management

Background• Burnout caused from chronic occupational stress• Medical providers at high risk for burnout

• Physicians: 37.9%

• Mental health (MH) professionals: 21-67%

• Suspected unique risk for military providers• OEF/OIF/OND

• Med-evacs: 23,742

• Incidence of TBI: 250,000

• New cases of PTSD: 130,000

• Personnel and leadership turnover

• Deployment exposure

Background• Significant burnout in deployed providers

• Primary care: 45%

• MH professionals: 33%

• All providers: 15%

• 2011 study at NMCSD showed average levels of burnout in MH providers

• No other reports of burnout in other military specialities

• Current study goal: Examine burnout and well-being in a broad range of military provider specialities

Method• Command process improvement initiative • All LIPs at NMCSD invited to voluntarily

complete survey• Survey

• Administered electronically

• Anonymous

• Maslach Burnout Inventory (MBI)• Emotional Exhaustion (EE)

• Depersonalization (DEP)

• Personal Accomplishment (PA)

• Demographic and work variables

Participants

25-30 31-40 41-50 >500

50100150200

Age

ActiveDuty

Civilian/Contractor

050

100150200250300

Military Status Job TitlePhysicianDentistNP/CRNAPA CSocial WorkHygienistPsychologistPsychiatristOther

DirectorateMedical

Surgery

Mental Health

Dental

Other

MBI Results

EmotionalExhaustion

Depersonalization PersonalAccomplishment

230

364

46

140

114

103

153

45

374

MBI Subscales

highmediumlow

Comparison of MBI Scores

Personal

Accomplis

hment

Emotional Exh

austi

on

Depersonali

zation

0

10

20

30

40

NMCSD Normative Sample for MedicineNormative Sample for Mental Health

Results• Military providers’ burnout comparable or lower than civilian

counterparts

• No effect for deployments on active duty providers

• Emotional exhaustion related to more collaterals and hours worked

• Personal accomplishment higher for older participants

• Highest frustrations with admin support and work/life balance

• Physical and religious activity potential protective factors

Conclusions• Implement programs that foster awareness and prevention of

burnout for providers

• Enact safeguards for distribution of equitable collaterals and workloads

• Monitor providers with several collaterals and many hours worked

• Support religious and physical activities as potential buffers to stress

• Continue to assess burnout and further assess areas of support and well-being

Study 2: Operational Stress among

SERE InstructorsCollaborators:

Navy SERE Schools

Background• SERE school is a stressful environment

for students and instructors

• Survival training and interrogation simulation: dual role

• Little information available on SERE instructors

• Current study goal:

Understand overall levels of stress and predictors of stress among SERE instructors

Method• Three year, longitudinal study of the stress process

StrainStressors

Individual & Organizational

Factors

Sample Characteristics: 68 SERE Instructors

Female16%

Male84%

Asian4%

Black or African American

12%

Hawaiian or Pacific Islander

2%

White68%

Other15%

Active Duty47%

Government Service

2%

Contractor52%Never

6.00%

1 to 343.30%

4 to 629.90%

7 to 913.40%

More than 97.50%

Gender Ethnicity

Deployments Status

Good Work/Life Balance and Higher than Average Stress

SERE Comparison0

10

20

30

40

20.417.0

Percieved Stress

SERE Comparison01234567

2.53.3

Work Conflicts With Fam-ily

SERE Comparison01234567

1.72.7

Family Conflicts With Work

Instructors Score High on Protective Factors

SERE Comparison0

22

44

66

88

65.960.5

Resilience - RSES

SERE Comparison0

1

2

3

4

54.1

3.6

Resilience - BRS

SERE Comparison0

15

30

45

6046.1

40.9

Unit Cohesion

Moderate Burnout and Alcohol Use Slightly Above Cut-Off

SERE Comparison0

20

40

60

80

100

50 50

Professional-Quality of Life

SERE Comparison01234567

2.2 2.3

Burnout

SERE Comparison0

10

20

30

40

9.4 8.0

Alcohol Use

Conclusions• Mostly healthy and resilient population

• Well-suited for the task of SERE school instructor

• Opportunity to learn about resilience

• Evidence of some stress and maladaptive coping• Looking ahead

• Comparing across sites

• Contractor vs. active duty vs. GS

• How scores change over time and in response to other changing conditions

Collaborators:

Dr. Rollin McCraty, Director, Institute of HeartMath

CAPT Lori Laraway, Warfighter Resiliency Director, NECC

Study 3:Coherence Training for

Military Personnel: Initial Results

Background• Autonomic Nervous System (ANS) dysregulation

found with chronic stress and PTSD• Heart Rate Variability (HRV) is a measure of ANS

imbalance• Low HRV associated with:

• poor health, cardiovascular disease, depression, chronic anger, insomnia, and anxiety disorders, such as PTSD

• Biofeedback/physiological monitoring has been shown to increase HRV

• Military using biofeedback interventions

Study Goal• Evaluate effectiveness of the Coherence

Advantage program, a biofeedback-based intervention, for stress reduction and performance enhancement

Method• Design: Quasi-experimental

• 10 Independent Duty Corpsman classes were sequentially assigned to either Coherence Advantage or Progressive Muscle Relaxation (PMR)

• Assessed: Baseline, 3 mos., 6 mos., and 12 mos. intervals

Method• Intervention

• Coherence Advantage participants assigned emWave to practice self-regulation techniques and HRV coherence feedback

• PMR participants assigned an MP3 player with pre-recorded instructions for full and abbreviated versions of PMR

• Compliance emails and phone reminders every 2 weeks

Method

Method

Results• 192 service members recruited to participate

• 94 in Coherence Advantage condition

• 98 in Progressive Muscle Relaxation condition

• A total of 118 remained in the study for 12 months• 38.5% attrition rate

• Most were dropped from school or rolled over to another class

• Only 1 person asked to be removed from the study

• Variable attrition rate• Coherence condition: 44.7%

• PMR condition: 32.7%

Never9%

120%

237%

320%

4+8%

Participants

Female24%

Male76%

Asian8%

Black or African American

17%

Hawaiian or Pacific Islander

4%White55%

Other16%

Divorced15%

Married63%

Separated3%

Never Married

19% Deployments

Outcomes

T1 T2 T3 T40

10

20

30

40

50

60

70

80

67.0 68.3 70.5 71.1

T1 T2 T3 T40

5

10

15

20

25

30

35

40

14.116.5

14.5 13.7

Resilience

P<.01

Perceived Stress

P<.001 P<.001

P<.001

T1 T2 T3 T40

2

4

6

8

10

12

14

16

18

20

7.36.3 6.6

5.8

T1 T2 T3 T40

5

10

15

20

25

4.3 4.3 4.23.1

P<.05

Sleep

P<.01 P<.05Depression

P<.001

P<.01

Outcomes

T1 T2 T3 T417

27

37

47

57

67

77

28.5 27.4 25.5 24.0

T1 T2 T3 T40

5

10

15

20

4.4 5.03.7 3.4

P<.05

P<.001

Post-Traumatic Stress

Anxiety

P<.001

P<.05

Outcomes

Skills Practice

P<.05

P<.001

T2 T3 T40

1

2

3

4

5

6

7

1.20.7 0.5

Practice with Device

Day

s

P<.001

T2 T3 T40

1

2

3

4

5

6

7

1.7 1.51.1

Practice without Device

Day

s

P<.001

T2 T3 T40

1

2

3

4

5

6

7

1.2

0.4 0.3

1.190.89 0.71

Practice with Device

Coherence

PMR

Day

s

P<.01

Skills Practice

Conclusions• IDC school is stressful, especially 1st quarter

• Changes over time may be an artifact of a stressful training environment

• Absence of control group makes it difficult to draw conclusions about overall effectiveness

• Future analysis of dose-response

• Participants did not practice skills often• Future interventions should focus on ways to increase time

spent practicing techniques

• Coherence appears to be no more effective than PMR

• PMR is less costly and doesn’t require a device

Stress Resilience Training System

Collaborators:Don Chartrand: Ease Interactive

Dr. Gershon Weltman & Amos Freedy, Perceptronics Solutions Inc.

Dr. Rollin McCraty, Institute of HeartMath

Stress Resilience Training System (SRTS)

is funded by DARPA and ONR

Study Goal• Evaluate the effectiveness of iPad-based

SRTS application

Method• Recruitment/Consent

• Group informational session

• One-on-one informed consent with NCCOSC research staff

• Randomization to 1/3 conditions• Classroom training

• One session, 2 hours

• Participants take the iPad home and use it for two months

• Practice time: about 15 minutes per day

• Biweekly emails/phone calls to participants as reminders to practice

Three Conditions• Stress Resilience Training System (SRTS)

• Two-hour training

• iPad with SRTS app includes: HRV biofeedback-driven games, videos and self quizzes

• Progressive Muscle Relaxation (PMR)• Two-hour training

• iPad with PMR app includes two PMR videos and a pdf document that take the participant through the steps of PMR

• Waitlist Control• Receive SRTS training and iPad after two months

SRTS Condition• iPad app teaches

stress regulation skills through the use of HRV biofeedback

PMR Condition

Assessment• Baseline, 2 months and 4 months

• Self-report measures previously validated with military populations

• Compliance• Self-report

• Usage data collected by app

The Sample

Sex• Females = 18.1%

• Males = 80.6%

Rank• E2-E5 = 76.4%

• E6-E9 = 19.2%

• O1-O4 = 2.7%

SRTS = 24; PMR = 21; Control = 17

In a relationship• Yes = 68.1%

• No = 20.8%

T1 T20

1

2

3

4

5

Depression

PHQ

Sco

re

Results

T1 T26

8

10

12

14

16

18

Perceived Stress

PSS

Scor

e

STRSPMRCONTROLT1 T2

545658606264666870

Resilience

RSES

Sco

re

p<.05 p<.05

p<.05

SRTS vs. PMR Usage

Before stressful event with iPad

Before stressful event without iPad

During a stressful event without iPad

1 2 3 4 5

2.9

3.1

3.3

2.0

2.3

2.0

How often do you use (PMR or SRTS): PMR SRTS

SRTS

PMR

0 5 10 15 20 25 30 35 40 45

41.3

16.4

Mean total number of sessions:

“Never” “Very Often”

Note. All differences are significant at p < .05

Conclusions• SRTS is a promising approach to engage

sailors to learn skills• Limited or no training required

• Teaches to different learning styles

• Self-paced

• Information in small bites

• No internet required• Ideal for remote locations

• Next steps• Trial with Marine Corps command

• Use platform to deliver content tailored for other groups

Overall Conclusions• Ongoing surveillance of stress in the military,

especially for at-risk groups

• Identify and further understand resilience factors and environments to bolster wellbeing in service members and individuals who support them

• Technology can aid in reducing stress but the tool needs to be of interest to the population