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Background and Aims More than 292 million people are living with hepatitis B worldwide and are at risk of death from liver cirrhosis and liver cancer. The World Health Organization (WHO) has set global targets for the elimination of viral hepatitis as a public health threat by 2030. However, current levels of global investment in viral hepatitis elimination programmes are insufficient to achieve these goals. Methods To catalyse political commitment and to encourage domestic- and international-financing, we used published modelling data and key stakeholder interviews to develop an investment framework to demonstrate the return on investment for viral hepatitis elimination. Results The framework utilizes a public health approach to identify evidence-based national activities that reduce viral hepatitis-related morbidity and mortality, as well as international activities and critical enablers that allow countries to achieve maximum impact on health outcomes from investment to achieve WHO 2030 elimination targets. Conclusion Focusing on hepatitis B, this health policy paper employs the investment framework to estimate the substantial economic benefits of investing in the elimination of hepatitis B and demonstrates how such investments could be cost-saving by 2030., Graphical abstract, Highlights • The WHO has set global targets for elimination of hepatitis B by 2030 • To date, global investment in hepatitis B elimination activities has been limited • We have developed a global investment framework for the elimination of hepatitis B to guide domestic and international investment • This Health Policy paper outlines evidence to support the financial returns on investment in hepatitis B elimination, identifies national and international activities to achieve hepatitis B elimination targets and identifies potential funding sources • The goal of this investment framework is to pave the way for countries to build the economic case for investment in national hepatitis B elimination programmes.

Objective The study aims to evaluate the ability of self-management programmes to change the healthcare-seeking behaviours of people with Chronic Obstructive Pulmonary Disease (COPD), and any associations between programme design and outcomes. Methods A systematic search of the literature returned randomised controlled trials of SMPs for COPD. Change in healthcare utilisation was the primary outcome measure. Programme design was analysed using the Theoretical Domains Framework (TDF). Results A total of 26 papers described 19 SMPs. The most common utilisation outcome was hospitalisation (n = 22). Of these, 5 showed a significant decrease. Two theoretical domains were evidenced in all programmes: skills and behavioural regulation. All programmes evidenced at least 5 domains. However, there was no clear association between TDF domains and utilisation. Overall, study quality was moderate to poor. Conclusion This review highlights the need for more alignment in the goals, design, and evaluation of SMPs. Specifically, the TDF could be used to guide programme design and evaluation in future. Practice implications Practices have a reasonable expectation that interventions they adopt will provide patient benefit and value for money. Better design and reporting of SMP trials would address their ability to do so.

WHO has set global targets for the elimination of hepatitis B and hepatitis C as a public health threat by 2030. However, investment in elimination programmes remains low. To help drive political commitment and catalyse domestic and international financing, we have developed a global investment framework for the elimination of hepatitis B and hepatitis C. The global investment framework presented in this Health Policy paper outlines national and international activities that will enable reductions in hepatitis C incidence and mortality, and identifies potential sources of funding and tools to help countries build the economic case for investing in national elimination activities. The goal of this framework is to provide a way for countries, particularly those with minimal resources, to gain the substantial economic benefit and cost savings that come from investing in hepatitis C elimination.

Background The hospital patient pathway for having treatment procedures can be daunting for younger patients and their family members, especially when they are about to undergo a complex intervention. Opportunities to mentally prepare young patients for their hospital treatments, e.g. for surgical procedures, include tools such as therapeutic clowns, medical dolls, or books and board games. However, while promising in reducing pre-operative anxiety and negative behaviours, they may be resource intensive, costly, and not always readily available. In this study, we co-designed a digital hospital information system with children, parents and clinicians, in order to prepare children undergoing medical treatment. Method The study took place in the UK and consisted of two parts: In part 1, we purposively sampled 37 participants (n=22 parents, and n=15 clinicians) to understand perceptions and concerns of an hospital information platform specifically design for and addressed to children. In part 2, 14 children and 11 parents attended an audio and video recorded co-design workshop alongside a graphic designer and the research team to have their ideas explored and reflected on for the design of such information technology. Consequently, we used collected data to conduct thematic analysis and narrative synthesis. Results Findings from the survey were categorised into four themes: (1) the prospect of a hospital information system (parents’ inputs); (2) content-specific information needed for the information system (parents’ and clinicians’ inputs); (3) using the virtual information system to connect young patients and parents (parents’ inputs); and (4) how to use the virtual hospital information system from a clinician’s perspective (clinicians’ inputs). In contrast, the workshop highlighted points in times children were most distressed/relaxed, and derived the ideal hospital visit in both their and their parents’ perspectives. Conclusions The findings support the use of virtual information systems for children, in particular to explore and learn about the hospital, its facilities, and the responsibilities of healthcare professionals. Our findings call for further investigations and experiments in developing safer and more adequate delivery of care for specific age groups of healthcare users. Practical and theoretical implications for improving the quality and safety in healthcare delivery are discussed.

BackgroundAs systems become more complex, shared leadership (SL) has been suggested to have a dominant role in improving cross-functional working tailored to organisational needs. Little, however, is known about the benefits of SL in healthcare management, especially for UK’s recently formed integrated care system (ICS). The aim of this study was to understand current attitudes, barriers and needs of clinical and non-clinical managers sharing leadership responsibilities in the ICS.MethodTwenty clinical and non-clinical leaders in 15 organisations were interviewed to understand current cross-functional leadership collaborations, and the potential SL may have on the recently established ICS in the National Health Service (NHS). The data were transcribed and analysed thematically.ResultsFindings showed perceptions and experiences of clinical and non-clinical healthcare management in relation to: (1) motivation to execute a leadership position, including the need to step up and a sense of duty; (2) attitudes towards interdisciplinary working, which is reflected in conflicts due to different values and expertise; (3) SL skills and behaviours, including the need for mutual understanding and cooperative attitudes by means of effective communication and collaboration; and (4) barriers to achieve SL in the ICS, such as bureaucracy, and a lack of time and support.ConclusionsSL may help improve current leadership cultures within the NHS; however, for SL to have a tangible impact, it needs to be delivered as part of leadership development for doctors in postgraduate training, and development programmes for aspiring, emerging and established leaders, with clear lines of communication.

Bronchiectasis is an increasingly common chronic respiratory disease which requires a high level of patient engagement in self-management. Whilst the need for self-management has been recognised, the knowledge and skills needed to do so— and the extent to which patients possess these—has not been well-specified. On one hand, understanding the gaps in people’s knowledge and skills can enable better targeting of self-management supports. On the other, clarity about what they do know can increase patients’ confidence to self-manage. This study aims to develop an assessment of patients’ ability to self-manage effectively, through a consensus-building process with patients, clinicians and policymakers. The study employs a modified, online three-round Delphi to solicit the opinions of patients, clinicians, and policymakers (N = 30) with experience of bronchiectasis. The first round seeks consensus on the content domains for an assessment of bronchiectasis self-management ability. Subsequent rounds propose and refine multiple-choice assessment items to address the agreed domains. A group of ten clinicians, ten patients and ten policymakers provide both qualitative and quantitative feedback. Consensus is determined using content validity ratios. Qualitative feedback is analysed using the summative content analysis method. Overarching domains are General Health Knowledge, Bronchiectasis-Specific Knowledge, Symptom Management, Communication, and Addressing Deterioration, each with two sub-domains. A final assessment tool of 20 items contains two items addressing each sub-domain. This study establishes that there is broad consensus about the knowledge and skills required to self-manage bronchiectasis effectively, across stakeholder groups. The output of the study is an assessment tool that can be used by patients and their healthcare providers to guide the provision of self-management education, opportunities, and support.

AimSystem leadership is the requirement for a leader of a single organisation to operate on behalf of a wider system, rather than their individual organisation. It is not clear to what extent the current policy landscape supports leaders in managing misalignment between the needs of their organisation and the wider system, as many national structures still emphasise a focus on individual organisations. This study aims to understand how Chief Executives implement system leadership in practice when faced with decisions that benefit the system to the detriment of their own trust.MethodologySemi-structured interviews were conducted with ten Chief Executives from a range of trust types to understand their perceptions and decision-making process in practice. Semantic thematic analysis was used to draw out themes in relation to how Chief Executives approach decisions which weigh up the system and organisation.ResultsThemes raised by interviewees included both advantages (such as support in managing demand) and disadvantages (such as increased bureaucracy) of system leadership and practical considerations in operationalisation (such as the importance of interpersonal relationships). Interviewees endorsed system leadership in principle, but did not feel that the organisational incentives as currently structured support the implementation of system leadership in practice. This was not seen as a major challenge or impediment to effective leadership.ConclusionAs a specific policy area, a direct focus on systems leadership is not necessarily helpful. Chief Executives should be supported to make decisions in a complex environment, without a specific focus on healthcare systems as a unit of operation.

Viral hepatitis is a leading cause of morbidity and mortality worldwide, but has long been neglected by national and international policymakers. Recent modelling studies suggest that investing in the global elimination of viral hepatitis is feasible and cost‐effective. In 2016, all 194 member states of the World Health Organization endorsed the goal to eliminate viral hepatitis as a public health threat by 2030, but complex systemic and social realities hamper implementation efforts. This paper presents eight case studies from a diverse range of countries that have invested in responses to viral hepatitis and adopted innovative approaches to tackle their respective epidemics. Based on an investment framework developed to build a global investment case for the elimination of viral hepatitis by 2030, national activities and key enablers are highlighted that showcase the feasibility and impact of concerted hepatitis responses across a range of settings, with different levels of available resources and infrastructural development. These case studies demonstrate the utility of taking a multipronged, public health approach to: (a) evidence‐gathering and planning; (b) implementation; and (c) integration of viral hepatitis services into the Agenda for Sustainable Development. They provide models for planning, investment and implementation strategies for other countries facing similar challenges and resource constraints.

INTRODUCTION: Monitoring a patient's vital signs forms a basic component of care, enabling the identification of deteriorating patients and increasing the likelihood of improving patient outcomes. Several paper-based track and trigger warning scores have been developed to allow clinical evaluation of a patient and guidance on escalation protocols and frequency of monitoring. However, evidence suggests that patient deterioration on hospital wards is still missed, and that patients are still falling through the safety net. Wearable sensor technology is currently undergoing huge growth, and the development of new light-weight wireless wearable sensors has enabled multiple vital signs monitoring of ward patients continuously and in real time. Areas covered: In this paper, we aim to closely examine the benefits of wearable monitoring applications that measure multiple vital signs; in the context of improving healthcare and delivery. A review of the literature was performed. Expert commentary: Findings suggest that several sensor designs are available with the potential to improve patient safety for both hospital patients and those at home. Larger clinical trials are required to ensure both diagnostic accuracy and usability.

This article was published in International Journal of Stress Management on 24 August 2017 (online), available at http://dx.doi.org/10.1037/str0000079

Background User interface (UI) design features such as screen layout, density of information, and use of colour may affect the usability of electronic prescribing (EP) systems, with usability problems previously associated with medication errors. To identify how to improve existing systems, our aim was to explore prescribers’ perspectives of UI features of a commercially available EP system, and how these may affect patient safety. Methods Two studies were conducted, each including ten participants prescribing a penicillin for a test patient with a penicillin allergy. In study 1, eye-gaze tracking was used as a means to explore visual attention and behaviour during prescribing, followed by a self-reported EP system usability scale. In study 2, a think-aloud method and semi-structured interview were applied to explore participants’ thoughts and views on prescribing, with a focus on UI design and patient safety. Results Study 1 showed high visual attention toward information on allergies and patient information, allergy pop-up alerts, and medication order review and confirmation, with less visual attention on adding medication. The system’s usability was rated ‘below average’. In study 2, participants highlighted EP design features and workflow, including screen layout and information overload as being important for patient safety, benefits of EP systems such as keeping a record of relevant information, and suggestions for improvement in relation to system design (colour, fonts, customization) and patient interaction. Conclusions Specific UI design factors were identified that may improve the usability and/or safety of EP systems. It is suggested that eye-gaze tracking and think-aloud methods are used in future experimental research in this area. Limitations include the small sample size; further work should include similar studies on other EP systems.

Background and importance User interface design features, such as screen layout, density of information, position of messages and use of colour, may affect the usability of electronic prescribing (EP) systems, with usability problems previously associated with medication errors. Aim and objectives To explore users’ perspectives of the on-screen design features of a commercially available EP system and how these are perceived to affect patient safety. Material and methods The study was conducted at a large London teaching hospital during 2018–2019. Participants were recruited via adverts on the intranet; all prescribers with experience using the EP system were eligible to participate. We used a mixed qualitative approach. First, prescribers were asked to conduct a prescribing task for a simulated patient using a think aloud approach. Second, we conducted a semi-structured interview with each participant to explore their views in more detail, with a focus on patient safety. Interview questions were developed based on the literature and then piloted. Think aloud and interview transcripts were analysed inductively using a thematic approach. Ethics approval was obtained. Results Ten participants took part (three registrars, three foundation year 1 doctors, two foundation year 2 doctors and two pharmacist prescribers). Key themes from the think aloud and interview transcripts included: (1) EP design features and process flow; (2) benefits of EP systems; and (3) suggestions for improvement. For instance, design features such as screen features and layout were discussed with regards to impact on workflow, as well as ‘information overload’. Suggestions for improvement were made in relation to embedding trust guidelines and making changes to system design (eg, colour, fonts, customisation) to increase information visibility and enhance overall attention. Lastly, a need was expressed for better support for interacting with patients while using the system, as well as making drug–drug interaction alerts more targeted to support medication safety while also avoiding alert fatigue. Conclusion and relevance We identified specific interface design factors that may improve the usability and/or safety of EP systems, which can be used to inform future experimental research in this area. Limitations include the small sample size; further work should include similar studies on other EP systems. References and/or acknowledgements Conflict of interest Corporate sponsored research or other substantive relationships: I supervise a PhD student who is partly funded by a supplier of a commercial electronic prescribing system.

Background and importance User interface design can have a significant impact on interactions with online systems. Eye tracking is generally accepted as a useful method to study performance in areas such as interpretation of medical imaging. However, there is little evidence of its use to study user interactions with electronic prescribing (EP) systems, an area in which failure to see and act on key information is particularly critical. Aim and objectives To explore the feasibility of using eye tracking to study EP users’ visual attention and behaviour, with a focus on safe prescribing. Material and methods The study took place at a London teaching hospital from 2018 to 2019. Participants were recruited via the organisation’s intranet. Any prescriber with experience of the EP system was eligible to participate. We used Tobii Pro X3-120 integrated screen monitor trackers in a simulation setting. Participants were asked to complete a prescribing task for a test patient, which included prescribing penicillin for a patient with a penicillin allergy. Data collected included videos of the screen showing the participant’s scan paths. We segmented the data according to when the user switched screens, and calculated percentage of time spent looking in each of the four quadrants of the screen for each. The study was approved as a service evaluation. Results Ten prescribers participated. Overall, the highest percentages of fixation points were at the top left and right corners of the screen, where information is provided on allergies and patient information, respectively. However, each prescriber initially prescribed a penicillin and was stopped only by a pop-up alert. The highest number of fixation points was observed during review of the prescription and final signature, followed by review of the allergy alert and the search for drug names and dosages. Conclusion and relevance Eye tracking is a feasible method for studying EP interactions. The findings will be used to plan a larger evaluation, with the aims of understanding how screen design can help or hinder patient safety, and how type and positioning of decision support information influences the likelihood of it being acted on. Limitations include small sample size; further work should also explore how gaze patterns may differ between novices and experts. References and/or acknowledgements Conflict of interest Corporate sponsored research or other substantive relationships: I supervise a PhD student who is part funded by a supplier of a commercial electronic prescribing system.

Highlights • Self-management programmes are a popular way to engage patients in their own care. • Inconclusive results stem from inconsistency in study conditions, design, and reporting. • Behaviour change theories can identify appropriate outcome measures for evaluation. • Programmes should be developed with theory and patient-centricity in mind., Objective The study aims to evaluate the ability of self-management programmes to change the healthcare-seeking behaviours of people with Chronic Obstructive Pulmonary Disease (COPD), and any associations between programme design and outcomes. Methods A systematic search of the literature returned randomised controlled trials of SMPs for COPD. Change in healthcare utilisation was the primary outcome measure. Programme design was analysed using the Theoretical Domains Framework (TDF). Results A total of 26 papers described 19 SMPs. The most common utilisation outcome was hospitalisation (n = 22). Of these, 5 showed a significant decrease. Two theoretical domains were evidenced in all programmes: skills and behavioural regulation. All programmes evidenced at least 5 domains. However, there was no clear association between TDF domains and utilisation. Overall, study quality was moderate to poor. Conclusion This review highlights the need for more alignment in the goals, design, and evaluation of SMPs. Specifically, the TDF could be used to guide programme design and evaluation in future. Practice implications Practices have a reasonable expectation that interventions they adopt will provide patient benefit and value for money. Better design and reporting of SMP trials would address their ability to do so.

Purpose Research in psychology or management science has shown that shared leadership (SL) enhances information sharing, fosters participation and empowers team members within the decision-making processes, ultimately improving the quality of performance outcomes. Little has been done and, thus, less is known of the value and use of SL in acute healthcare teams. The purpose of this study is to (1) explore, identify and critically assess patterns and behaviour of SL in acute healthcare teams; and (2) evaluate to what extent SL may benefit and accomplish safer care in acute patient treatment and healthcare delivery. Design/methodology/approach The authors conducted a review that followed the PRISMA-P reporting guidelines. A variety of sources were searched in April 2018 for studies containing primary research that focused on SL in acute healthcare teams. The outcome of interest was a well-specified assessment of SL, and an evaluation of the extent SL may enhance team performance, lead to safer patient care and healthcare delivery in acute healthcare teams. Findings After the study selection process, 11 out of 1,383 studies were included in the review. Studies used a qualitative, quantitative or mixed-methods approach. Emerging themes based on behavioural observations that contributed to SL were: shared mental model; social support and situational awareness; and psychological safety. High-performing teams showed more SL behaviour, teams with less seniority displayed more traditional leadership styles and SL was associated with increased team satisfaction. Research limitations/implications Evidence to date suggests that SL may be of benefit to improve performance outcomes in acute healthcare team settings. However, the discrepancy of SL assessments within existing studies and their small sample sizes highlights the need for a large, good quality randomized controlled trial to validate this indication. Originality/value Although studies have acknowledged the relevance of SL in healthcare service and delivery, a systematic, evidence-based and robust evaluation of behavioural patterns and the benefits of SL in this field is still missing.

Simulation has been applied as a tool for learning and training in sports, psychology and medicine for some time, but its current use and potential for training musicians is less well understood. The aim of this study was to explore musicians’ perceptions and experiences of using simulated performance environments. Nine conservatory students performed in two simulations, each with interactive virtual elements and vivid environmental cues: a recital with a virtual audience and an audition with virtual judges. Qualitative data were collected through a focus group interview and written reflective commentaries. Thematic analysis highlighted the musicians’ experiences in terms of (1) their anticipation of using the simulations, (2) the process of performing in the simulations, (3) the usefulness of simulation as a tool for developing performance skills and (4) ways of improving simulation training. The results show that while simulation was new to the musicians and individual levels of immersion differed, the musicians saw benefits in the approach for developing, experimenting with and enhancing their performance skills. Specifically, the musicians emphasised the importance of framing the simulation experience with plausible procedures leading to and following on from the performance, and they recognised the potential for combining simulation with complementary training techniques.

IntroductionSimulation-based training (SBT) on shared leadership (SL) and group decision-making (GDM) can contribute to the safe and efficient functioning of a healthcare system, yet it is rarely incorporated into healthcare management training. The aim of this study was design, develop and validate a robust and evidence-based SBT to explore and train SL and GDM.MethodUsing a two-stage iterative simulation design approach, 103 clinical and non-clinical managerial students and healthcare professionals took part in an SBT that contained real-world problems and opportunities to improve patient safety set within a fictional context. Self-report data were gathered, and a focus group was conducted to address the simulation’s degree of realism, content, relevance, as well as areas for improvement.ResultsParticipants experienced the simulation scenario, the material and the role assignment as realistic and representative of real-world tasks and decision contexts, and as a good opportunity to identify and enact relevant tasks, behaviours and knowledge related to SL and GDM. Areas for improvement were highlighted with regard to involving an actor who challenges SL and GDM; more preparatory time to allow for an enhanced familiarisation of the content; and, video debriefs to reflect on relevant behaviours and team processes.ConclusionsOur simulation was perceived as an effective method to develop SL and GDM within the context of patient safety and healthcare management. Future studies could extend this scenario method to other areas of healthcare service and delivery, and to different sectors that require diverse groups to make complex decisions.

Auditioning is at the very center of educational and professional life in music and is associated with significant psychophysical demands. Knowledge of how these demands affect cardiovascular responses to psychosocial pressure is essential for developing strategies to both manage stress and understand optimal performance states. To this end, we recorded the electrocardiograms (ECGs) of 16 musicians (11 violinists and 5 flutists) before and during performances in both low- and high-stress conditions: with no audience and in front of an audition panel, respectively. The analysis consisted of the detection of R-peaks in the ECGs to extract heart rate variability (HRV) from the notoriously noisy real-world ECGs. Our data analysis approach spanned both standard (temporal and spectral) and advanced (structural complexity) techniques. The complexity science approaches—namely, multiscale sample entropy and multiscale fuzzy entropy—indicated a statistically significant decrease in structural complexity in HRV from the low- to the high-stress condition and an increase in structural complexity from the pre-performance to performance period, thus confirming the complexity loss theory and a loss in degrees of freedom due to stress. Results from the spectral analyses also suggest that the stress responses in the female participants were more parasympathetically driven than those of the male participants. In conclusion, our findings suggest that interventions to manage stress are best targeted at the sensitive pre-performance period, before an audition begins. *** For a video summary of this article please see http://researchonline.rcm.ac.uk/id/eprint/1809/ ***

Music is increasingly recognised as important in facilitating healthy ageing, yet little is known of what musicians themselves learn when they teach older adults. This article reports the practices of the Rhythm for Life project at the Royal College of Music in the UK, in which conservatoire students taught 10-week programmes of group instrumental music lessons to adult beginners aged between 46 and 90 years. In order to interrogate what four student-teachers learned from their engagement with the project, qualitative data were collected through open-ended questionnaires, diaries and video-stimulated recall interviews. Findings demonstrated that the student-teachers reformulated the ways in which they thought about and taught older adult learners, and developed skills and knowledge relevant to a wide range of educational contexts. The article concludes that models similar to Rhythm for Life, where conservatoires facilitate opportunities for students to teach older adults, may be an effective means of establishing meaningful learning experiences for music students and older adults alike.

Financial markets typically undergo periods of prosperity followed by periods of stagnation, and this undulation makes it challenging to maintain market efficiency. The efficient market hypothesis (EMH) states that there exist differences in structural complexity in security prices between regular and abnormal situations. Yet, despite a clear link between market acceleration (cf. recession in security prices) and stress in physical systems, indices of financial stress still have significant scope for further development. The overarching aim of this work is therefore to determine the characteristics of financial indices related to financial stress, and to establish a robust metric for the extent of such 'stress'. This is achieved based on intrinsic multiscale analysis which quantifies the so called complexity-loss hypothesis in the context of financial stress. The multiscale sample entropy and our proposed Assessment of Latent Index of Stress methods have successfully assessed financial stress, and have served as a measure to establish an analogy between transitions from 'normal' (relaxed) to 'abnormal' (stressed) financial periods with the sympatho-vagal balance in humans. Four major stock indices of the US economy over the past 25 years are considered: (i) Dow Jones Industrial Average, (ii) NASDAQ Composite, (iii) Standard & Poor's 500, and (iv) Russell 2000, together with FTSE 100, CAC 40 and exchange rates. Our findings support the EMH theory and reveal high stress for both the periods of Internet bubble burst and sub-prime mortgage crisis., This work was supported by the Financial Signal Processing Laboratory (http://www.fsplab.com/) at Imperial College London. The guest editor coordinating the review of this manuscript and approving it for publication was Prof. Ali N. Akansu.

The Electrocardiogram (ECG) collected in real-life scenarios is often noisy and contaminated with motion artefacts. This study proposes a new framework to analyse the heart rate variability (HRV) in mobile scenarios by introducing novel R-peak detection and HRV detrending algorithms. The R-peak detection combines matched filtering and Hilbert transform, while detrending the HRV is performed using empirical mode decomposition with novel physically meaningful stopping criteria. Next, four quantitative metrics-sample entropy, LFhrv, HFhrv and LF/HF ratio — are used to estimate stress levels in two public speaking events: (i) a presentation in front of an audience and (ii) an interactive poster presentation, both at ICASSP 2015. We show that the proposed framework makes it possible to detect distinctive ‘stress-patterns’ in the structural complexity of the HRV, thus verifying the complexity-loss hypothesis in physiological research.

Performing music in public is widely recognized as a potentially stress-inducing activity. However, despite the interest in music performance as an acute psychosocial stressor, there has been relatively little research on the effects of public performance on the endocrine system. This study examined the impact of singing in a low-stress performance situation and a high-stress live concert on levels of glucocorticoids (cortisol and cortisone) in 15 professional singers. The results showed a significant decrease in both cortisol and cortisone across the low-stress condition, suggesting that singing in itself is a stress-reducing (and possibly health-promoting) activity, but significant increases across the high-stress condition. This is the first study to demonstrate that singing affects cortisol as well as cortisone responses and that these responses are modulated by the conditions of performance. *** For a video summary of this article please see http://researchonline.rcm.ac.uk/id/eprint/1808/ ***

Musicians typically rehearse far away from their audiences and in practice rooms that differ significantly from the concert venues in which they aspire to perform. Due to the high costs and inaccessibility of such venues, much current international music training lacks repeated exposure to realistic performance situations, with students learning all too late (or not at all) how to manage performance stress and the demands of their audiences. Virtual environments have been shown to be an effective training tool in the fields of medicine and sport, offering practitioners access to real-life performance scenarios but with lower risk of negative evaluation and outcomes. The aim of this research was to design and test the efficacy of simulated performance environments in which conditions of “real” performance could be recreated. Advanced violin students (n = 11) were recruited to perform in two simulations: a solo recital with a small virtual audience and an audition situation with three “expert” virtual judges. Each simulation contained back-stage and on-stage areas, life-sized interactive virtual observers, and pre- and post-performance protocols designed to match those found at leading international performance venues. Participants completed a questionnaire on their experiences of using the simulations. Results show that both simulated environments offered realistic experience of performance contexts and were rated particularly useful for developing performance skills. For a subset of 7 violinists, state anxiety and electrocardiographic data were collected during the simulated audition and an actual audition with real judges. Results display comparable levels of reported state anxiety and patterns of heart rate variability in both situations, suggesting that responses to the simulated audition closely approximate those of a real audition. The findings are discussed in relation to their implications, both generalizable and individual-specific, for performance training.

For musicians, performing in front of an audience can cause considerable apprehension; indeed, performance anxiety is felt throughout the profession, with wide ranging symptoms arising irrespective of age, skill level and amount of practice. A key indicator of stress is frequency-specific fluctuations in the dynamics of heart rate known as heart rate variability (HRV). Recent developments in sensor technology have made possible the measurement of physiological parameters reflecting HRV non-invasively and outside of the laboratory, opening research avenues for real-time performer feedback to help improve stress management. However, the study of stress using standard algorithms has led to conflicting and inconsistent results. Here, we present an innovative and rigorous approach which combines: (i) a controlled and repeatable experiment in which the physiological response of an expert musician was evaluated in a low-stress performance and a high-stress recital for an audience of 400 people, (ii) a piece of music with varying physical and cognitive demands, and (iii) dynamic stress level assessment with standard and state-of-the-art HRV analysis algorithms such as those within the domain of complexity science which account for higher order stress signatures. We show that this offers new scope for interpreting the autonomic nervous system response to stress in real-world scenarios, with the evolution of stress levels being consistent with the difficulty of the music being played, superimposed on the stress caused by performing in front of an audience. For an emerging class of algorithms that can analyse HRV independent of absolute data scaling, it is shown that complexity science performs a more accurate assessment of average stress levels, thus providing greater insight into the degree of physiological change experienced by musicians when performing in public.