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