Physician wellness/concepts
Psychological Skills to Improve Emergency Care Providers’ Performance Under Stress

https://doi.org/10.1016/j.annemergmed.2017.03.018Get rights and content

Stress experienced by emergency medical providers during the resuscitation of critically ill or injured patients can cause cognitive and technical performance to deteriorate. Psychological skills training offers a reasonable and easily implemented solution to this problem. In this article, a specific set of 4 performance-enhancing psychological skills is introduced: breathe, talk, see, and focus. These skills comprise breathing techniques, positive self-talk, visualization or mental practice, and implementing a focus “trigger word.” The evidence supporting these concepts in various domains is reviewed and specific methods for adapting them to the environment of resuscitation and emergency medicine are provided.

Introduction

Psychological skills training is the systematic acquisition and practice of different psychological techniques to improve cognitive and technical performance.1 Occupations including the performing arts, military, athletics, and astronautics have benefited from various forms of psychological skills training.2, 3, 4

This article describes 4 distinct, evidence-based performance-enhancing psychological skills (PEPS): breathe, talk, see, and focus.5 These 4 skills can be used as a form of psychological skills training adapted to emergency medicine. In this article, the individual components of PEPS will be discussed and the evidence to support their effectiveness will be reviewed.

Section snippets

Stress, Arousal, and Performance in Emergency Medicine

Emergency care providers’ jobs are stressful.6 A variety of factors—including unpredictable patient volume and acuity, circadian rhythm disruptions, and lack of previous relationship with the patient—contributes to this stress. Management of critically ill or injured patients demonstrates characteristics of “crisis” situations: circumstances rife with uncertainty, potential threat to life, necessity to take immediate action, and at least partial inability to control aspects of the situation.7

Applications of Psychological Skills to Mitigate Stress and Improve Resuscitation Performance

Recent studies show that certain psychological interventions, such as training in mindfulness (being aware of one’s feelings, thoughts, and sensations in the moment) and meditation, can help individuals cope with stress and anxiety in different circumstances.29, 30, 31, 32, 33 PEPS is distinct from these concepts because it encompasses a variety of techniques for regulating arousal and improving performance just before or in moments of high stress. It has its foundation in other evidence-based

Breathe: Using Performance-Enhancing Breathing

The first element, breathe, is the ability of providers to learn to control and focus their attention on their breathing. Stress often causes an immediate spike in physiologic arousal; the application of breathing techniques offers a quick and effective means through which to decrease that response. Different breathing techniques have been used and developed during thousands of years to improve performance in various martial arts, meditative practices, and yoga.35

Respiration is the only

Talk: Positive Self-talk

Positive self-talk consists of an internal monologue with specific content and structure of statements.44 Self-talk plays a vital role in how individuals react to different situations, leading some psychologists to refer to it as “the key to cognitive control.”15, 45

Elite athletes use self-talk to improve their performance. Training athletes to be able to feed themselves positive suggestions as part of an internal monologue is an important aspect of sports psychology.41, 42 Research suggests

See: Use Visualization Exercises, Imagery, and Mental Practice

The third element, see, is the ability of providers to visualize the steps of a procedure or clinical skill they are preparing to perform. This process acts as a blueprint or mental video of what an effective performance should look like. Visualizing a procedure, task, or scenario can serve as a practice run in the provider’s mind before he or she actually performs the procedure. Rehearsing in one’s mind activates the same neurologic network needed to successfully perform a task.54

The idea of

Focus: Develop and Use a “Trigger Word”

Focus is the fourth element. In this step, the provider should use a trigger word before starting a procedure or resuscitation. The trigger word can be any one the provider chooses that brings his or her full attention to the task at hand. It can be subvocalized, whispered, or simply spoken aloud. The word acts as a cognitive signal flare, prompting the provider to shift his or her attention to a single, prioritized task. The key purpose of the trigger word or phrase is to activate the

Conclusion

Emergency medicine providers are tasked with performing highly complex skills and assessments under dynamic conditions in which every second matters and the cost of failure is significant. Performing effectively amid these pressures, demands, and expectations involves more than clinical knowledge and skill. The internal state of the provider is also critical. There is a wealth of evidence in the medical literature and from research conducted in other high-pressure-performance settings that

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    Supervising editor: Megan L. Ranney, MD, MPH

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    Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist.

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