Stress innoculation training
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Transcript of Stress innoculation training
Stress Innoculation Training
Jeremy MasonED Registrar SCGH
Thursday 18th February 2016
The process of showing people what can happen to you under stress
Developing and building tools to cope with the physiological response to stress
“Innoculating” by exposing yourself to the stressors that you’re likely to experience in your field
What is it?
1) To gain knowledge and familiarity with a stressful environment
2) To develop and practice task-specific skills, including psychological skills as well as decision making faculties, to be performed under stress
3) To build confidence in an individuals capabilities
Goals of SIT
Simple message; How you train is how you fight
Tachycardia can make you stupid
If you let your vital signs and catechloamine surge over take your cognitive ability – it will completely ruin your ability to manage a stressful situation
You will encounter stress and its negative effects taking care of critically ill or injured patients
Preparation is required to perform at your very best
Why its important?
Developed by psychologist Donald Meichenbaum in 1980’s
Multifaceted type of Cognitive Behavioural Therapy designed to help individuals cope with stress
Based on the concept of inoculation – prepares a person to be more resistant to stress through prior exposure to milder forms of stress
Widely used by Military and NASA to mitigate stress in a variety of situations
Psychological technique used in PTSD, anxiety and anger
Starting to be used in medical education to help improve performance in emergency and critical care
Dedicated EMCRIT & iTeachEM Podcasts on the topic + dedicated preconference workshop at SMACC Chicago 2015
Stress Inoculation Training
Based on appraisal and coping behaviour
◦ We experience stress when we evaluate the relationship we have with our environment as being:
Over demanding
Beyond our ability to cope with
Posing a threat to our health and wellbeing
Transactional model of stress
We construct stories about ourselves
These stories affect persons ability to cope with stress
Being a “Victim” vs being and “Overcomer”
SIT uses this perspective to help people construct life narratives to help them cope with stress
Constructive narrative perspective
SIT teaches a broad range of coping skills
These coping skills can be applied in any stressful situation
SIT comprises 3 overlapping phases
How does it work?
Phase 1 – Information Provision
◦ Learns about the nature and impact of the human stress response◦ Made aware of their ability to solve problems◦ Encouraged to think adaptively
Phase 2 – Skills acquisition
◦ Develops and refines behavioural, technical & cognitive skills
Phase 3 – Application and practice
◦ Practice skills learnt◦ Graded exposure to increasingly stressful situations
Stress inoculation training
Educational phase
Show people the physiological response to stress
There’s a difference between having knowledge stored in your memory and having the ability to apply that knowledge and get things done when you’re stressed or when things aren’t going well
Same applies with technical skills e.g. Intubating a mannequin in a quiet room vs massive haematemesis with SATS dropping
Tell people there’s a way to improve your performance
Phase 1; Information Provision
Grossman & Sidel 1996 review– Examined combat and the warrior mindset
Used heart rate as a surrogate for amount of stress
Looked at skills performance and how people respond
Found an “ideal” level of arousal
As stress increased there was a point where they became overloaded and experienced a deterioration in cognitive and skills performance
Physiological Effects of Stress
http://www.thinklikeahorse.org/flight_or_fight.html
Yerkes Dodson Law
https://www.adelaide.edu.au/uni-thrive/revive/stress/
Performance deterioration as a function of heart rate
From On Combat, by Lt. Col Dave Grossman
Building skills and muscle memory to perform skills when it really counts
Develop technical & non technical skills needed to perform in the resus environment without the addition of stressful stimuli
Goals:◦ Learn & develop constructive coping mechanisms◦ Develop effective performance habits
Stage 2; Skills acquisition and consolidation
Think Feel Act
Cognitive control techniques
Provide control over distracting or stress inducing thoughts
Individual is taught to recognize distracting thought processes and stop them
Cognitive control techniques
Negativethought STOP
Replace with positive, task-
focused thoughts
Controlling specific physiological parameters
Progressive relaxation◦ Not always feasible when faced with deteriorating patient
Controlled breathing◦ Respiration is the only autonomic function that can be controlled and modified
consciously
◦ Can be used to control emotional response
◦ Slow breathing Reduced heart rate Reduced stress
◦ Seppala et al 2014 RCT Breathing techniques decrease stress response, anxiety and hyper arousal in combat
veterans with PTSD
◦ Tactical breathing – 4 second method
Physiological control techniques
“The same neural pathways are recruited and the same neurochemicals are secreted when we visualize doing something as when we engage in the actual acivity” 1
Lorello 2015 – Mental practice is effective at preparing teams for trauma resuscitation◦ 20 mins mental practice vs 20 mins ATLS Sim◦ Mental practice group increased scores for
teamworking behaviours
Mental practice and rehearsal
1 Weisinger H, Pawliw-Fry JP. Performance Under Pressure. New York, NY: Crown Business; 20152 Lorello, G. R., Hicks, C. M., Ahmed, S.-A., Unger, Z., Chandra, D., & Hayter, M. A. (2015). Mental practice: a
simple tool to enhance team-based trauma resuscitation. Canadian Journal of Emergency Medicine, FirstView, 1–7.
Training decision making skills◦ Eg algorithms and checklists
Overleaning technical skills
Teaching on communication
Team training / simulations
Other techniques
Take skills from Phase 2 and rehearse them in increasingly graduated stressful conditions
Allows trainees to experience in real time the performance challenges they will face in a specific setting
Reduces uncertainty and anxiety
Increases confidence when individuals realise they can overcome stressors
Phase 3; Application and practice
1) Performance diminishes under stress
2) Technical skill & knowledge necessary but not enough to perform effectively in stressful situations
3) Focus on developing the skills to perform under stress
4) No RCTs yet exploring SIT in resuscitation – some currently under way but needs further investigation
Summary
iTeachEM Podcast by Rob Rogers, Stress Inoculation Training http://iteachem.net/2014/12/stress-inoculation-training/
http://emcrit.org/blogpost/on-stress-inoculation-training/
http://emcrit.org/blogpost/performance-enhancing-psychological-skills/
http://emcrit.org/blogpost/flow/
https://www.adelaide.edu.au/uni-thrive/revive/stress
References
Weisinger H, Pawliw-Fry JP. Performance Under Pressure. New York, NY: Crown Business; 2015
Lorello, G. R., Hicks, C. M., Ahmed, S.-A., Unger, Z., Chandra, D., & Hayter, M. A. (2015). Mental practice: a simple tool to enhance team-based trauma resuscitation. Canadian Journal of Emergency Medicine, FirstView, 1–7.
M Seppälä, E., B Nitschke, J., L Tudorascu, D., Hayes, A., R Goldstein, M., T H Nguyen, D., … J Davidson, R. (2014). Breathing-Based Meditation Decreases Posttraumatic Stress Disorder Symptoms in U.S. Military Veterans: A Randomized Controlled Longitudinal Study. Journal of Traumatic Stress, 27(4), 397–405
References