Preparing for High Acuity Events: Simulation-Based Stress Inoculation Training

Health care contains many stressors for health professionals, both chronic and acute. There is accumulating evidence that clinical performance can be significantly impaired by stress responses during acute events, both in the psychology and healthcare domains. Paramedics, medical residents and surgeons have all shown impaired performance when faced with high acuity situations that triggered subjective and physiological stress responses. Impairments have been observed in the ability to perform drug calculations, trauma and cardiac resuscitations, in technical skills, as well as on tasks that rely on memory recall. In some cases, the magnitude of the stress response has been associated with the degree of performance impairments. In many studies in which performance impairments have been observed, baseline levels of performance were acceptable, suggesting that these impairments are not due to a lack of relevant knowledge or skills required to provide patient care in these situations.

The findings of impaired performance with stress responses suggests that training for high acuity events needs to go beyond training that is oriented solely towards the acquisition of clinical skills and knowledge. Training needs to also include interventions aimed at developing the trainees' ability to cope with stressors and to minimize their personal stress responses. In the psychology, aviation and military domains, several approaches have been developed to optimize performance during stressful events. These can be categorized either as skills-based training (providing individuals or teams with the specific skills required during a crisis) or as stress management interventions (modifying the individual's appraisal of potentially stressful situations).

The implementation of skill based training, such as crisis resource management (CRM), has resulted in improved performance in team interactions. However, CRM-type of training requires that health professionals be able to remember those skills that were learned, yet memory recall is often impaired under stress. As for overlearning, it can lead to rigid approaches to problem solving, and is less likely to be efficient in dynamic situations that require flexibility in approaches and judgment. Therefore, educators also need to develop complementary approaches to train health professionals in recognizing stress responses and in managing and minimizing their emotional responses. Stress management approaches are focused on reducing the emotional and physiological response itself. The premise is that by reducing the stress response, the cognitive facilities (including recall of relevant knowledge and skills) required during a high acuity situation are more likely to remain intact.

Two important predictors of stress responses to high acuity events are individuals' coping styles and their cognitive appraisals of the situation. Task-oriented coping styles, as well as appraisals of perceived resources being equal to or above the perceived demands of a situation, are associated with lower stress responses in high acuity events. As such, stress management approaches focused on coping styles and cognitive structuring are likely to reduce the subjective and physiological stress responses of clinicians and trainees during high acuity events.

A promising method of reducing stress responses and performance impairments under acutely stressful conditions is stress inoculation training (SIT). This 3-phase cognitive-behavioural approach to stress management has proven effective in domains outside of healthcare. SIT has been found to be effective in reducing general state anxiety, performance anxiety (anxiety specific to the skills being addressed in the training), and in enhancing performance under stress. SIT appears to be effective when run with groups of 8-10 participants and it can be implemented successfully without an inordinate number of training sessions. Finally, the beneficial effects of the SIT can generalize to novel stress conditions and novel tasks, which is crucial for any applied area in which the conditions of real life environments are often dynamic, ambiguous and emergent.