Stress innoculation training

Stress innoculation training

1. Stress Innoculation Training Jeremy Mason ED Registrar SCGH Thursday 18 th February 2016

2. The process of showing people what can happen to you under stress Developing and building tools to cope with the physiological response to stress “ I nnoculating ” by exposing yourself to the stressors that you’re likely to experience in your field What is it?

3. 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

4. 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?

5. 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

6. 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

7. 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

8. 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?

9. 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

10. 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

11. 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

12. http://www.thinklikeahorse.org/flight_or_fight.html

13. Yerkes Dodson Law https://www.adelaide.edu.au/uni-thrive/revive/stress/

14. Performance deterioration as a function of heart rate From On Combat, by Lt. Col Dave Grossman

15. 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

16. Cognitive control techniques Provide control over distracting or stress inducing thoughts Individual is taught to recognize distracting thought processes and stop them

17. Cognitive control techniques

18. 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  R educed 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

19. “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; 2015 2 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.

20. Training decision making skills Eg algorithms and checklists Overleaning technical skills Teaching on communication Team training / simulations Other techniques

21. 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

22. 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

23. 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

24. 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