Learning to Take the Heat: The Problem with Stress

As an emergency physician, you've studied and trained for every manner of injury, illness, and critical disease. While that knowledge goes far in offering confidence in a treatment plan, it doesn't always help manage the stress of that crisis. Stress Inoculation Training can help.

The job of an emergency physician is stressful.¹ Multiple factors, such as unpredictable patient volume and acuity, fatigue, and lack of previous relationship with the patient, all play a part in the magnitude of this stress. In fact, managing critically ill or injured patients manifests characteristics of “crisis situations”: circumstances rife with uncertainty, clear and present danger to life, the need to take immediate action, and at least partial inability to control certain features of the situation.² These situations, where patients’ lives are on the line, necessitate optimal performance.

However, stress compromises our ability to perform at our very best by degrading important faculties. For example, one very well-documented effect is attentional narrowing. In the world of engineering psychology, this is referred to as “increased selectivity.”³ People have a tendency to lose global situational awareness and focus on particular tasks. Evidence demonstrates this can be a result of numerous stressors including noise, visual distractions, or time pressure.^4,5 Under these circumstances, study participants have shown decreases in detection of objects in the peripheral vision.⁶ Furthermore, the problem is more than just a decrease in visual field or breadth of what an individual’s mind can attend to, it is also a failure to focus on the most appropriate information. As it turns out, we seem to focus on what we perceive to be the most important information⁷ (an adaptive cognitive triage mechanism of sorts), but this could be dangerous if the stimulus that grabs our attention is not the most critical to actually solving the clinical puzzle presented.⁸ Not surprisingly, the fewer pieces of information we have to process, the lower the cognitive load, and the lesser the tunnelling effect.⁹

This attentional narrowing is further complicated by increased perseveration: continuing or repeating a given action or plan that they have recently used or regularly apply. As stress increases and cognitive faculties deteriorate, people are more likely to continue trying the same unsuccessful solution despite clear evidence of its failure.^10,11 Cognitive psychologists have suggested this aligns with current understanding of human behaviour: people tend to default to what is known or familiar in times of stress. Thus, in a problem-solving situation, the range of options is not only narrow, but we fail to explore other solutions even if the narrow range of options are failing.^12,13 The result is a potentially dangerous enhanced effect of confirmation bias.¹⁴

Stress also decreases information processing and working memory.^15,16,17 It affects both internal dialogue¹⁸ (keeping information at hand) and also causes increased distraction of attention.¹⁹ The compromise to working memory is more pronounced the more complex the task. Researchers have demonstrated marked effects on complex problem solving²⁰ and decision problems that involve special visualization for successful resolution.²¹ So, our ability to perform clinically important cognitive tasks (such as thinking about the underlying pathological process) is inhibited, to an extent, and takes more time.

These effects have specific implications for emergency physicians. The dynamic nature of practice in the emergency department and levels of stress make it uniquely prone to these aforementioned cognitive sequelae, resulting in mistakes and medical error.²² While many authors discuss the complexities of general diagnostic errors or medication errors,^23,24,25 a few have identified errors involved in common emergency procedures.^26,27 For example, providers can lose situational awareness during endotracheal intubation. Cemalovic et al found that emergency physicians’ perception of time to intubation was significantly skewed. Providers believed they were actually much faster than they were in reality. Possibly more concerning was the fact that providers consistently underestimated how often their patients desaturated during intubation attempts.²⁸ 

The Training Paradigm of Stress Inoculation
Stress Inoculation Training (SIT) is a multifaceted type of cognitive-behavioral therapy that was originally designed to help individuals cope with stress. It was initially developed by psychologist Donald Meichenbaum in the 1980s and has been employed to mitigate the sequelae of stress in a variety of situations. The essence of SIT is that by exposing people to increasing levels of perceived stress, they practice employing different coping skills and eventually develop increased tolerance or immunity to a particular stimulus. ²⁹

This cognitive behavior therapy paradigm was adapted over time and applied to preparing individuals to perform in high-stress, high-risk occupations. Organizations like NASA and the military, although not formally referring to it as SIT, have applied these concepts to improve performance and reduce stress in their respective domains.^30-35 In particular, various organizations within the Special Operations have adopted these concepts and incorporate them into training and selection.³⁶

The general goals of incorporating this paradigm into technical skills training and simulation are:^37,38

1. To gain knowledge and familiarity with the stressful environment and each individual’s unique emotional response as well as its effects on cognition
2. To develop and practice task-specific skills (including various psychological skills), as well as decision making faculties, to be performed under stress
3. To build confidence in one’s capabilities

Structure and Content of Stress Inoculation Training for Emergency Medicine
Driskell and Johnson suggested some slight modifications to the initial SIT training structure proposed by Meichenbaum. These adjustments made training adaptable to both a broader domain of technical skills and preparation for performance in a stressful environment (as opposed to a therapeutic modality after a stressful incident). The general structure of this training was divided into three phases:³⁵

1. Information provision – This phase provides information on the human stress response, conditions participants should expect to encounter, and other preparatory information
2. Skills acquisition – This is phase is designed to develop and refine behavioral, technical, and cognitive skills
3. Application and practice – This phase includes practicing skills under conditions that approximate the operational environment and that gradually attain the level of stress expected

Information Provision
In the first phase, preparatory information is provided to trainees. They are taught about the physiological response to stress normally and how these natural physiological mechanisms can interfere with the specific cognitive processes and technical skills during resuscitation. In this phase of training it should be made clear that deterioration in their faculties is normal; it is nearly universal, it is a natural result of the trainees’ psychological response, and it is no way a sign of weakness or inadequacy. This explanation sets realistic cognitive and behavioral expectations of how trainees will respond to a medical emergency. Having realistic expectations, as it turns out, is crucial. Just by having more reasonable expectations, people perform better under stress.³⁸        

Another important part of this phase is making it clear that providers aren’t helpless in the face of these hard-wired stress responses. The belief that people have the capacity to exert control over their behavior is also critical. This understanding of self-efficacy and maintenance of an internal locus of control has been linked to improved performance in different domains.^39,40 It also allows you to predict potential areas of weakness and motivate individuals to obtain the necessary skills to improve their response under stress.^41,42

Skills Acquisition
The second phase of this training paradigm is, perhaps, the most important phase. Many would argue that it is more important than the application of stressful stimuli. Furthermore, it should be emphasized that inadequate development of this phase, skipping it entirely, or moving too quickly to apply stressful stimuli can be counterproductive.^45,46

Skills acquisition develops the host of technical and non-technical skills needed to perform in the resuscitation environment under low or “no-stress” conditions. The goal is to learn and develop constructive coping mechanisms and to develop effective performance habits. The fundamental technical skills of emergency medical care must be established in conjunction with various cognitive and behavioral techniques. Trainees and experienced clinicians can both be taught to develop various psychological tools to help manage stress.

While teaching the knowledge and technical skills needed to perform well during medical emergencies has been well-developed by clinician educations over the years, psychological skills instruction is somewhat novel. These skills have been developed in other domains by performance psychologists and have yielded significant benefits.⁴³ Some of these skills include breathing techniques, positive self-talk, mental practice, and attention control techniques.⁴⁴ These psychological skills can be taught and incorporated in a domain specific fashion. For example, trainees can be taught to perform structured visualization and mental practice of emergency endotracheal intubation as they are preparing their equipment for the procedure.

Other authors have established several other important aspects of skills acquisition.³⁵ Some of these include training decision-making skills (eg, institution specific airway algorithms or checklists), over-learning technical skills (eg, central venous access, laryngoscopy, or chest tube insertion), communication, and team training. Although beyond the scope of this article, each of these topics is important in its own right and worth mentioning.

Application and Practice
This phase is designed to take the psychological and technical skills learned and rehearse them under increasingly stressful conditions. This allows trainees to experience, in real-time simulation, the various performance challenges they will face in a specific (OR, ED, or prehospital) setting. It also reduces uncertainty and anxiety as well as increases confidence when individuals realize that they can overcome stressors. Finally, stimuli experienced during stress training are less distracting when experienced in real life. Requisite to these desired effects is a graduated approach to stress exposure. It is by incrementally increasing the stress that the desirable outcomes, familiarity, resilience, and confidence, are developed. ^35,37,41

The application of stressful stimuli can be generally divided into three categories: intrinsic, extrinsic, and socio-evaluative stressors.^47,48 Intrinsic stressors represent elements specific to the clinical scenario (eg, simulated disease severity or difficulty of interventions required). Extrinsic stressors represent other elements not directly linked to the simulated patient’s clinical condition (e.g. noise in the room, poor lighting, malfunctioning equipment). Socio-evaluative stressors are both a natural extension of the simulation (i.e. peers and instructors watching and evaluating trainee performance in real time) or artificially generated as part of the simulation (eg, an intimidating consultant telling the trainee to "hurry up".)

What remains unclear, and difficult to generalize, is when, how, and to what degree to increase these individual stressful stimuli. In the absence of clear evidence, it stands to reasons that these must be carefully titrated by skilled clinician educators to the skill level and education needs of individual trainees. Small increases in stimuli may push novices to be overwhelmed while more senior trainees can be pushed with a high degree of many stressful stimuli.

Incorporating SIT into Existing Training Models
One of the most promising training techniques where SIT may be ideal for incorporation is in-situ simulation. This type of simulation occurs in the actual clinical environment where people work with the actual staff on duty at the time.⁴⁹ Moving the simulation out of the lab and into the real clinical space has showed promise by better retention of clinical concepts⁵⁰ and enhanced team performance.^51,52 It has even demonstrated evidence that it helps teams identify critical patient deterioration earlier than traditional training^53,54 and even improved cardiac arrest outcomes in one center.⁵⁵ Finally, it has the added benefit of identifying latent safety threats and opportunities for process improvement.^56,57 

The first two phases of SIT might be conducted in a more traditional learning environment such as the classroom or simulation lab. However, once trainees move to the third phase of application and practice, conducting training in situ may be advantageous. This is because many distractions and stressful stimuli are specific to environment in which resuscitation occurs.^35,37 Therefore, there may be significant benefit to allowing trainees to work through stressors and challenges that might be encountered in a real clinical environment.^58.59,60

Conclusion
Clinician educators have worked diligently and made significant advances over the years in developing effective methods for providing residents with the knowledge and technical skills needed to manage medical emergencies. While knowledge and technical skills are certainly required to treat critically ill patients, they may not be sufficient. The unique stressors experienced in the emergency department may cause untoward effects on cognition and skills performance. SIT offers a promising solution that can incorporate existing medical education modalities into an accepted cognitive and behavioral training framework.

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