PerformanceOptimisation–TheSynopsis

LearningObjectives

• Stress-describeitseffectsonthephysiologyandpsychologyofourperformance

• OutlineaThreatVersusChallengeassessment• Describestrategiestoincreaseself-awarenesstohelpoptimize

performance• Outlinestrategiestooptimizeperformance-before,duringandafterthe

stressfuleventfortheindividualandtheteam

Stress-describethephysiologyandthepsychologyofwhatitisandwhyitaffectsus?

Stressisdefinedasastateofmentaloremotionalstrainortensionthatresultsfromadverseordemandingcircumstances.(Dictionary,2017)Stresscausesaseriesofusefulphysiologicalandpsychologicalreactionsthatallowsourbodytoperformatpeaklevelsinordertosurvivetheperceivedthreat.Thisisthefight-flightresponsethathasallowedhumanstosurviveallofthethingsthathavetriedtokillusduringourevolutionaryprocess.

Thestress-performancecurveshownbelowdemonstrateshowhumansfunctionmosteffectivelywhenfacedwithamoderatedegreeofchallenge.

Stress-PerformanceCurve(Bradbary,2014)

Physiological

Complexsetofcardiovascular,neurological,respiratory,cutaneousandgastrointestinaleffects.

Psychological

Stresscanimpairthefollowing5psychologicalfactors-

• Perceptionofproblem• Analysisofproblem• Decisionmaking• Motoraction.• Situationalawareness.

Thelongtermimpactsofstresscanbesignificantforthehealthoftheindividual,bothphysicalandpsychological.Howwethinkaboutandprepareforstressfulsituationsmayhaveasignificantinfluenceourownwellbeingandperformancethroughoutourlives.

Stressasaconceptofneithergoodorbad.

InherTedTalk,KellyMcGonigaldiscussedaboutthefactthatperhapsit’snotaboutstressbeinggoodorbad.(McGonigal,2013)

Stressitselfmaybeneutral

Itishowweinteractwiththestresswhichdeterminesit’seffect.

Thatifyouexperiencestressanddonotbelievethatstressisharmful-thestressitselfmayactuallybeprotective!

Perhaps,thequestionthatweneedtoaskis-Isitthebeliefthatstressisbadforyouthatiscausingyouharmratherthanthestressitself?

SimonSinekalsoexploresourinterpretationofstressfulstimulusfurther,aslistedintheresourcesbelow,discussingthatnervousnessandstresscanbereframedinsomesituationsasexcitement.(Sinek,2014)

InhisextensivepostonhisFirst10inEMBlog,JustinMorgensterndiscussesthattheinteractionbetweenthephysiologicalandpsychologicalfactorsmaybemodulatedthroughStressInoculationTraining.(Morgenstern,2017)HediscussesthedifferencebetweenfeelingThreatenedandChallengedinthesettingofperformance.

ThreatVersusChallengeassessment

Differentindividualscanperceiveasingledifficultordemandingeventindifferentways.Itmaybeperceivedaseitherathreatorachallenge.Peoplefeelthatsomethingisachallengewhentheyfeelthattheyhaveadequateresourcestomeetthedemands.Incontrast,whentheindividualfeelsoverwhelmedbywhatisaskedofthem,orfeelsthatthereisactualpersonaldangerinvolved,thentheeventisperceivedasathreat.

Challenge

Resources>Demand

Emergencystaffwillrecognisethis–it’stheidealdayatwork.Thedayfliesby,we’vehadabusybutmanageabledayatworkandleaveourdepartmentstiredbuthappy/exhilarated.

Threat

Demand>Resources

EmergencyStaffwillalsoknowthisone–thedaysweareunderstaffed,overcrowdedandseemtohaveeverysickpatientintheStateappearinoneshift!Wefinishthedayexhausted,disgruntledandunabletofindsatisfactioninanyoftheworkwehaveachieved.

Butwhydoesthisevenmatter?

No-oneissuggestingthatwejustacceptthesecondshiftastherealityofourjob.Ofcourse,itwouldbewonderfulifwecouldfixthesystem,butbydevelopingstrategiestooptimiseourabilitytoworkinthechallengedstate,webetterprepareourselvestoperformeffectivelyattimesofheightenedstress.Thisallowsustoperformtemporarilyintheheightenedstate,thenrecoverandreturntothechallengedstatewhenthethreathaspassed.

Referencestostartwithfortheabove

McGonigal-TheEffectofstress-it'snotallbad

http://www.bouncebackproject.org/all-about-stress/

SimonSinek-Nervousnessversusexcitement

https://www.youtube.com/watch?v=GBF9xXhSFRc

Morgenstern-First10EMBlog

https://first10em.com/2017/03/13/performance-under-pressure/#more-4078

Describestrategiestoincreaseself-awarenesstohelpoptimizeperformance

Inordertomaximiseourperformance,weneedtoassessourownstateasbeingoneofeitherchallengeortreat.Inotherwords,weneedtodevelopskillsinself-awarenessofouremotionalstate.Self-awarenessisaveryactiveprocessandtakespractice.

Thissectioncanbeappliedtoanyworksettinginyourhospital

ItisparticularlyrelevanttothoseworkinginbusyCriticalCaresettings.

KnowYourselffirst,knowyourresponsenext.

Knowyourselffirst

Howareyougoingtocheckinwithyourselfinyouruniquelife,inyouruniqueworkplace?

Hereareafewpracticaltoolstoconsider

Whencanyouself-assesshowyouare?

• Whenyougettoworkandturnofthecarignition• Whenyousitbackintothecarafterwork

• WhenyougetaResuscall• Afteryoutakeareferralandputdownthephone

Askyourself5shortquestionstohelpoptimiseyoustateofperformance

‘AmIHALTS’?

• Hungry• Angry• Late• Tired• Stressed

Knowyouselfandyourdistractions-SocialMediaandemail

• Assessyourneedforconstantcontactibilityandupdates• Manageexpectationofthosearoundyou• Ensureyoucolleagues,familyandfriendsknowthatifsomebodyreally

wantsyoutheycancallyou• ConsideronlycheckingyouremailandSocialmediaonyourbreak• Avoidgettingworkemailstoyourhomeaccount.

(Morgenstern,2017)

Nowyourresponsenext

“Betweenstimulusandresponsethereisaspace.Inthatspaceisourpowertochooseourresponse.Inourresponseliesourgrowthandourfreedom.”

ViktorFrankl

SeesectionbelowonPerformanceforfurtherinformation

PleasealsoseeWRaPEMMindfulnessModule

Referencestostartwithfortheabove

Morgenstern-First10EMBlog

https://first10em.com/2017/03/13/performance-under-pressure/#more-4078

Outlinestrategiestooptimizeperformance-before,duringandafterthestressfuleventfortheindividualandtheteam.

StressPreparation-IndividualTechnique

Preventionisbetterthancure!

Howcanyouprepareforahighperformingstatebeforeyouevencomeacrossastressfulevent?

Optimiseself-awareness

• Whatisyourcurrentstate?• Whatisyouroptimalstate?• Whatfactorstriggerathreatresponseforyou?

Optimisegeneralhealth

• Nutritiono Fillthefridgebeforearunofnightsoreveningso Makeahealthymealthatwillfeedyouandyourfamilyfor3days!o Haveahealthysnackwithyourmorningcoffee

• Moveyourbodyo Exercise-inparticularoutsideingreenspaceo OptimiseyourCardiovascularfitness(egexercisebeforealate

shiftsothatyousleepbetterwhilston-call.)• Rest

o Optimiseyourrestperiodbeforeastressfulstimulus.

MentalRehearsalandVisualisation

• Mentallyrehearsehowyouwouldperformadifficultprocedurelikeasurgicalairway.

o Byrunningthroughthestepsinyourhead,youwillperformbetterwhenyoucometodothetaskunderpressure.

• Visualisationcanbeusedbeforeorduringstressfuleventooptimiseperformance

o PETLEPPisonemodeltoconsider

ThestepsofPETLEPPareasfollows

Physical

• Clothes,stance

Environment

• Similarenvironment

Task

• Eachtaskbeingperformedattheskilllevelofthepersondoingthetask

Timing

• Sametimeframetocompletethetask

Learning

• Evolvetheprocessovertime

Emotion

• Noise-beepingofamonitor.Canusesimmanforthisifrequired

Perspective

• Eitherdoingityourselftolookingatyourselfdoingit

Useyourbreath

• Optimiseyourparasympatheticnervoussystem• ConsiderSquare/CombatBreathing• Closeyoureyesoryoucandoitwithyoureyesopenifonthefloorat

worko Breathinfor4secso Holdinfor4secso Breathoutfor4secso Holdoutfor4secs.

§ Eachroundtakes16secs.

Idothiswhentoworkinthecarandturnofftheignition.Idoitwithmysunglassesonbutyouwilljustlooklikeyou’rehavinganapinthecarparkevenifyoudon’tdothis!

Optimiseyourthinking

• Cognitivereframingo Thisisausefulstrategytoovercomenegativeself-talkandfor

turningnegative(stressful)emotionalstatesintomorepositiveones.

o Often,wearesubjecttoaninternaldialoguewhichmaytellusthatwearenotgoodenoughordon’thavetheskillstohandleacertainsituation.

o Thismindsetdoesnotallowustoperformatourbest.o Byusingcognitivereframing,youcanquestionthesereactive

emotionalthoughtsandfeelings,calmourselvesandthenreframethethoughtsinamorerationalway.

o Byrecognisingourreactionswhentheyoccur,wegiveourselvestheopportunitytoquestionthetruthofthesethoughtsandtochooseourresponse.

o ThelinktoMindtoolswebsitelistedbelowshowsagoodexampleofthistechnique.

• Taskchunking

o Divideataskintoit’sindividualparttomakeitlessoverwhelmingo egyourshift,aprocedure,adifficultconversation

• Avoidaimingforperfection

o It’stheenemyofgood

Mindfulness

PleasealsoreviewthestrategiesoutlinedinWRaPmodulesonMindfulnessformoreinformationaboutusingthistechniqueforstressmanagement.

StressPreparation-TeambasedTechniques

Practicewithyourteam

• Simulation

o Immersive,resusbasedeventso Ideallyinsituino Practicewithadegreeofdifficultythatcreatesachallengestate

• Advancedplanninganddrills.• Developyourteam’ssharedmentalmodel.

Example:Performingarunthroughofyourfailedairwaydrillatthestartofashiftwiththeairwaydoctor&nurseallowsthemtodevelopasharedmentalmodelofthatsituationincaseitcomesuplaterintheshift.

TaskChunking

• Theabilitytotakelargecomplextasksandbreakthemdownintomoremanageablechunkscandecreasethestresslevelsintheteam.

• Gettoknowyourteam• Whenyouarriveatworkassesswhattheskillmixofyourteamis• Whatistheteam’sintrinsicresilience?• Isanyoneontheteaminneedofsupportonthisshift?• Organiseyourbreaksearly• Thenursesaremastersatthisorganisationalstrategy• Prioritiseyourteam’scomfortandwellbeingandtheywillperformbetter

ontheshift.

• MakeitOKforyourteammemberstospeakupwiththeyareHungry/Angry/Tired/Late/Stressed.

(Morgenstern,2017)

Duringstressfulstimulus

Knowyourself

• Again,askyourself-AmIHALTS?• Fixit• Gotothetoilet• HaveasnackbeforetheResusAmbulancegetstoyourED.

Knowyourenvironment

• Reassesstheskillmixofyourteam• Callforhelpearlyifskillmixisn’tsufficient.• Familiariseyourselfwithlocalprotocolsandpolicies.

Cognitiveoffloading

• UsealgorithmsieACLS

• Haveastandardairwaytrolleyandintubationapproachthroughouttheentireworkplace

Avoidmulti-taskingifpossible

(Morgenstern,2017)

ConsiderusingMikeLauria’sexcellentpneumonictoencompasstheabove‘BeatTheStressFool’

• Breath(Squarebreathing)• Talk(SelfTalk)• See(Visualisation)• Focus

(Weingart,2014)

Afterstressfulevent(particularlyaresuscitation)

Anticipateandacknowledgetheadrenalinedumporparasympatheticbacklashafterthestressfulevent

CreateaMentalGapbetweenworkandhome

• Efficiencyiskey.• Techniqueswhichmayhelpinclude• Prolongedmindfulhandwashbeforeleavingwork• Squarebreathingwhenyousitintoyourcarorthebushome• Journalingfor10minsbeforeyouleavework,• ConsidertheconceptofTheThirdSpaceasoutlinedbyAdamFraser

Debriefingandreflectivepracticealsoarekey.

PleaseseecurrentandfutureWRaPmodulesandBlogPostsforfurtherinformationonthistopic.

Begrateful-sayThankYou

• Toyourteam• Yourfamily• Themanatthecheck-outcounterintheshopsonyourwayhomefrom

work.

(Morgenstern,2017)

Referencestostartwithfortheabove

Morgenstern-First10EMBlog

https://first10em.com/2017/03/13/performance-under-pressure/#more-4078

SMACCPodcast27Feb2017(28mins)ChristopherHicks

IntotheDeep:DevelopingtheResuscitativeCollectiveUnconscious

Discussestherootsofgrit,resilience&poiseunderpressureandtakesadeepdiveintothechallenging,sometimesuglyworldofemotions,fear,anxietyandexpectations.Thegoodnewsisthescienceofhumanperformancehasevolved,andoffersinsightintohowtotrainforafocusedandenlightenedteammindset.

MindtoolsWebsite

CognitiveRestructuring

https://www.mindtools.com/pages/article/newTCS_81.htm

ThoughtAwareness&PositiveThinking

https://www.mindtools.com/pages/article/newTCS_06.htm

Lauria,M.J.,Gallo,I.A.,ColStephenRush,L.,Brooks,J.,Spiegel,R.,&Weingart,S.D.(2017).PsychologicalSkillstoImproveEmergencyCareProviders’PerformanceUnderStress.AnnalsofEmergencyMedicine,1–7.https://doi.org/10.1016/j.annemergmed.2017.03.018

ReferencelistforthisSynopsis

Bradbary,T.(2014).Howsuccessfulpeoplesquashstress.Forbes.Dictionary.(2017).Stress-aDefinition.Retrievedfrom

https://en.oxforddictionaries.com/definition/stressMcGonigal,K.(2013).TheEffectofstress-it’snotallbad.Retrievedfrom

http://www.bouncebackproject.org/all-about-stress/Morgenstern,J.(2017).StressInoculationTraining.Retrievedfrom

https://first10em.com/2017/03/13/performance-under-pressure/Sinek,S.(2014).Nervousnessversusexcitement.Retrievedfrom

https://www.youtube.com/watch?v=GBF9xXhSFRcWeingart,S.(2014).ToughnessPart1.Retrievedfrom

https://emcrit.org/emcrit/toughness-michael-lauria-i/