The ambulance arrives after a harrowing over-speed-limit drive in winter conditions. Paramedic and EMT are hyper alert as they approach the half-ton truck in the ditch where it landed after hitting a power pole. The driver is slumped over the steering wheel. Live electrical wires are on the ground. The truck appears to be electrified. Passing motorists have already stopped and are down in the ditch too. What next?
True scenario. Happened on an Alberta highway.
For paramedics and other emergency healthcare practitioners, staying clear-headed under this kind of stress is a job requirement.
Can you train for this? Yes.
STRESS, AROUSAL AND PERFORMANCE IN EMERGENCY HEALTHCARE
Stress experienced by emergency healthcare practitioners during high intensity events can cause mental and technical performance to decline – exactly what is not needed.
This is not personal. It’s not a reflection of practitioner competence. It’s simply how our human brains are wired. When our brain detects potential danger, it begins to shut down cerebral cortex functions (rational thinking ability). Breathing pattern, heart rate, muscle tension, pupil size and other physiological changes are activated. Our brain is getting our body ready for fight, flight or freeze.
In a crisis, we do need to be aroused past “normal.” But there is an optimum zone. We need enough arousal so we have enhanced situational awareness, but not so much that the brain begins to shut down our ability to think clearly and act precisely.
Four performance enhancing psychological skills can help you to manage inevitable stress responses and move into the optimum performance zone.
BEAT THE STRESS, FOOL!
Lauria et al[ ] describe an emergency medicine model for Performance Enhancing Psychological Skills (PEPS) that is represented by the initials BTSF. It consists of four elements that can be remembered with the phrase, “Beat The Stress, Fool!”
The authors say, “The whimsical nature of this [memory device] was intentional. If the mnemonics are capable of eliciting a smile, that facial expression alone may reduce stress.[ ] These four were chosen because of their ease of use, the efficacy demonstrated in medicine or comparable high-stress fields, and their rapidity in actual situations.”
Here are the four skills:
Beat = BREATHE (1-2-3-4)
The = TALK (positive self-talk)
Stress = SEE (mental rehearsal; visualize the steps)
Fool = FOCUS (use a “trigger word”)
The first element, breathe, is the ability to control and focus your attention on your breathing. Stress often causes an immediate spike in physiological arousal. Breathing techniques offer a quick and effective means to tone down that arousal response. Different breathing techniques have been used and developed during thousands of years to improve performance in martial arts, meditative practices, and yoga.[ ] Breathing techniques can work for healthcare practitioners too.
Breathing is the only autonomic function that can be controlled and modified consciously. That means it can be used to control the impact of your emotional responses. Lauria et al say, “There is a close, bidirectional relationship between respiration and emotional state. Using a slow, deep, controlled respiratory effort results in a reduction in pulse rate, an important physiologic marker of stress.[ ]”
In emergency medicine, one method that can be used to control the breathing cycle is the four-second method known as square or box breathing. This method is used by psychologists and others to help military and law enforcement personnel manage their response during acutely stressful incidents.[ ]
Here’s the technique:
1. Breathe in deeply through your nose for 4 seconds, engaging your diaphragm. Try to pull your breath right down to your abdomen.
2. Hold that in-breath for 4 seconds.
3. Breathe out slowly for 4 seconds.
4. Hold that empty space for 4 seconds.
Precise timing is not essential. The intent is simply to slow down the pace of your breathing and force deep breathing. Brain research shows that breathing in deeply through the nose taps into areas of your brain that help to quell fear and allow you to focus.[ ] Deliberately slowing down breathing gives your brain something to think about rather than panic. If your heart is racing, slow breathing helps to slow your heart rate. Plus, you are simply getting more oxygen into your brain and bloodstream.
TALK (POSITIVE SELF-TALK)
Self-talk plays a vital role in how you react to different situations. Some psychologists refer to it as “the key to cognitive control.”[ ] Research suggests self-talk can improve your belief that you can perform a task successfully.[ ]
Psychologists have found that there are different kinds of positive self-talk. These include:
– Instructional (“Focus on the needle angle going into the skin” or “Keep your knees bent.”)
– Motivational (“This patient needs my help to survive, and I can do it.”)
– Mood-related (“My fear is just a brain reaction. It’s not me.”)
– Self-affirmative (“I can do this. I know I can do this.”)
Guidelines have been developed on how to develop effective self-talk.[ ]
1. Keep phrases short and specific.
2. Use first person (“I” or “me”) and present tense (“I am now…”not “I will.” “I can” not “I could.”)
3. Use positive words and phrases not negative ones. (“This works” rather than “This will not fail.”)
4. When you recite a phrase to yourself, say it with intention.
5. Speak kindly to yourself.
6. Repeat phrases often.
SEE (VISUALIZE, IMAGINE, PRACTICE MENTALLY)
The third element, See, is the ability to visualize or imagine the steps of a procedure or clinical skill you are getting ready to perform.
Visualizing a procedure, task, or scenario is like a mental video; a practice run in your mind before you actually perform the procedure. Brain research has shown that mental rehearsing activates the same neurologic network that would be activated if you were actually performing the task.[ ] It’s like your brain doesn’t know the difference!
Sports psychology has been using this technique for decades. (“Imagine shooting the perfect basket. Imagine the muscles…”) Visualizing has been used successfully to achieve performance goals, improve concentration, enhance motivation, strengthen confidence, better control emotional responses, and overall prepare for performance.[ ]
The use of imagery to perform skills during critical law enforcement encounters was initially described in 1986. The technique was referred to as “crisis rehearsal.”
In The Tactical Edge, C. Remsberg outlines the necessity of deliberate mental rehearsal for conflict. In very stressful, potentially life-threatening situations that are not encountered often, visualizing your response to the situation can help enhance your ability to act. This is referred to as using one’s “mental movie” to improve performance . Remsberg says that mental practice “…‘programs’ your nerves and muscles to respond automatically and lessens your susceptibility to stress inference.”[ ]
In a different field, astronaut Chris Hadfield says that astronauts spend months or even years asking “What could go wrong?” and then visualizing how they could respond. When things do go wrong out in space, it is never exactly what they had imagined, but their advance mental preparation allows them to stay cool and handle the challenge.[ ] This “mental preparation” has saved astronauts’ lives more than once, including the time Hadfield was outside the space station, in space, and went blind.
In emergency medicine, mental imagery and visualization exercises may be particularly helpful in situations that require a structured algorithm or sequenced skills, such as Advanced Cardiac Life Support (ACLS).[ ]
Attempts to apply psychological skills training to the world of trauma resuscitation have also shown promise. In 2016, Lorello et al demonstrated that mental practice could be used to improve the performance of team-based skills in trauma resuscitation.[ ]
Research in medicine and other fields has shown that mental imagery is most effective when it includes specific, vivid details.[ ] In the case of a technical procedure, the visualization should include simulating the actual movements and steps involved in carrying out the task. That will further imprint on your mind how to respond ideally in that scenario.
FOCUS: DEVELOP AND USE A “TRIGGER WORD”
Focus is the fourth element of managing your stress response. In this step, you use a trigger word just before you start a procedure. The trigger word can be any one you choose that brings your full attention to the task at hand. You can say it in your mind, whisper it, or say it aloud.
The key purpose of the trigger word or phrase is to activate your selective attention. That allows you to focus only on the environment or patient cues that are relevant in the moment. Think of a trigger word as acting like a “spotlight.” It allows you to focus all your attention on important information or critical task. Everything that’s not relevant disappears from your mind.
You could use a trigger word like “focus” or “concentrate.” Here’s another example described by an emergency physician: “You pick up the number 10 blade from the thoracotomy tray. Just before you lay knife to skin, you take a deep breath and say the word ‘smooth’ to yourself. The word has the same effect now as it has had in your previous mental simulations. You focus on slow, controlled performance of the thoracotomy procedure.”[ ]
Acutely stressful situations cause heightened arousal, which can impair vital cognitive functions such as situational awareness, decision making, problem solving, and memory recall. These stress impacts can contribute to increased medical error and poor outcomes. Learning how to prepare and respond more effectively before potentially stressful situations, and how to refocus your attention within those moments, is of immense value.
Performing under pressure and responding to acute stressors will always be a challenge for emergency healthcare practitioners. Practicing the Breathe-Talk-See-Focus skills (“Beat the Stress, Fool!”) can help you better respond to acute stressors. You’ll translate all your knowledge and experience into peak performance when it really matters.
HONE CUE RECOGNITION
The mission of Hone Virtual Education is to help healthcare practitioners save lives by learning to perform at peak levels, capable of rapidly and correctly identifying diagnostic cues to enable correct clinical decisions in high pressure situations. One way Hone helps you do that is through CUE Recognition virtual simulation training modules you can download to your smartphone or tablet.
To find out more, visit www.honevirtualeducation.com where you can…
• Learn more about Hone CUE Recognition virtual simulation training;
• Be notified of updates and launch dates;
• Apply to be a beta tester as new modules are developed for healthcare practitioners in high pressure environments.
Bonnie Hutchinson is a writer and lifelong learner with degrees in Education and Whole Systems Design as well as extensive training and experience in adult learning and teaching. As an organizational and evaluation consultant, she’s worked with many healthcare and healthcare practitioner organizations. She’s bestselling author of Transitions: Pathways to the Life and World Your Soul Desires.
1 Lauria, M.J., Gallo, I.A., Rush, S., Brooks, J., Spiegel, R. Weingart, S.D., Psychological Skills to Improve Emergency Care Providers’ Performance Under Stress, Annals of Emergency Medicine, 2017; 70: 884-890.
2 Kraft, T.L. and Pressman, S.D. Grin and bear it: the influence of manipulated facial expression on the stress response. Psychological Science, 2012; 23: 1372–1378.
3 Singh, R.B., Wileczynska-Kwiatek, A., Fedacko, J. et al. Pranayama: the power of breath. International Journal of Disability and Human Development, 2009; 8: 141–153.
4 Philippot, P., Chapelle, G., and Blairy, S. Respiratory feedback in the generation of emotion. Cognition and Emotion 2002; 16: 605–627. Boiten, F.A., Frijda, N.H., Wientjes, C.J., Emotions and respiratory patterns: review and critical analysis, International Journal of Psychophysiology 1994; 17: 103–128. Openshaw, P., Breathing and control of heart rate, BMJ, 1978; 2: 1663–1664.
5 Grossman, D. On Combat: The Psychology and Physiology of Deadly Conflict in War and in Peace. PPCT Research Publications, Belleville, IL; 2008. Asken, M.J. and Grossman, D., Warrior Mindset: Mental Toughness Skills for a Nation’s Peacekeepers. Human Factor Research Group, Millstadt, IL; 2010. Bernier, F., Bouchard, S., Robillard, G. et al. Enhancing stress management skills in military personnel using biofeedback and immersion in a stressful videogame: a randomized control trial, Journal of Cybertherapy and Rehabilitation, 2011, 4: 209–212. Whitelock, K.A. and Asken, M.J. Code Calm on the Streets: Mental Toughness Skills for Prehospital Emergency Personnel. Sunbury Press, Mechanicsburg, PA; 2012.
6 Zelano, C., Jiang, H., Zhou, G., Arora, N., Schuele, S., Rosenow, J., Gottfried, J.A.,Nasal Respiration Entrains Human Limbic Oscillations and Modulates Cognitive Function, Journal of Neuroscience, 2016. Summary article at https://neurosciencenews.com/memory-fear-breathing-5699/
7 Lupien, S.J., Maheu, F., Tu, M. et al. The effects of stress and stress hormones on human cognition: implications for the field of brain and cognition, Brain and Cognition, 2007; 65: 209–237. Bunker, L., Williams, J.M., and Zinsser, N., Cognitive techniques for improving performance and self-confidence in J.M. Williams, V. Krane (Eds.) Applied Sport Psychology: Personal Growth to Peak Performance, 7th ed, McGraw Hill, New York, NY.
8 Hatzigeorgiadis, Z.N. Investigating the functions of self-talk: the effects of motivational self-talk on self-efficacy and performance in young tennis players, Sport Psychology, 2008; 22: 458–471. Hatzigeorgiadis, A., Zourbanos, N., Goltsios, C. et al, Self-talk and sports performance: a meta-analysis. Perspectives on Psychological Science, 2011; 6: 348–356. Tod, D., Hardy, J., and Oliver, E. Effects of self-talk: a systematic review. Journal of Sport Journal of Sport and Exercise Psychology, 2011; 33: 666–687.
9 Mikes, J. and Meyer, R., Basketball Fundamentals: A Complete Mental Training Guide, Human Kinetics Publishers, Champaign, IL; 1991.
10 Weisinger, H. and Pawliw-Fry, J.P. Performing Under Pressure: The Science of Doing Your Best When It Matters Most, Crown Business, New York, NY; 2015.
11 Martin, K.A., Moritz, S.E., Hall, C.R., Imagery use in sport: a literature review and applied model, Sport Psychology, 1999; 13: 245–268. Weinberg, R. Does imagery work? Effects on performance and mental skills, Journal of Imagery Research in Sport and Physical Activity, 2008; 3: 1–21.
12 Remsberg, C. The Tactical Edge: Surviving High Risk Patrol. Calibre Press, Inc, Northbrook, IL; 1986.
13 Chris Hadfield, An Astronaut’s Guide to Life on Earth, Random House Canada, Toronto ON, 2013.
14 Institute of Medicine. Hospital-Based Emergency Care: At the Breaking Point, National Academies of Sciences Engineering Medicine, 2017. https://www.nap.edu/catalog/11621/hospital-based-emergency-care-at-the-breaking-point
15 Lorello, G.R., Hicks, C.M., Ahmed, S.A. et al. Mental practice: a simple tool to enhance team-based trauma resuscitation, Canadian Journal of Emergency Medicine, 2016; 18: 136–142.
16 Smith, D., Wright, C., Allsopp, A. et al. It’s all in the mind: PETTLEP-based imagery and sports performance. Journal of Applied Sport Psychology, 2007; 19: 80–92. Smith, D., Wright, C.J., Cantwell, C., Beating the bunker, Research Quarterly for Exercise and Sport, 2008; 79: 385–391. Wright, C.J., Smith, D., The effect of PETTLEP imagery on strength performance, International Journal of Sport and Exercise Psychology, 2009; 7: 18–31.
17 Lauria et al, 2016, op. cit.
The Hone CUE Recognition App will soon be available on the App Store for early adopters. When it is available - you will be able to download it via the link below.