Review Paper Moderator/Discussant: Liselotte Dyrbye, MD The Effects of Acute Stress on Performance: Implications for Health Professions Education Vicki R. LeBlanc

Abstract Purpose search was limited to papers in English Conclusions This paper is a review of representative from all developed countries. Secondary Given the potential negative impact of research on the impact of acute stressors references were selected from primary stress on performance, and the on the clinical performance of individuals papers. individualistic way in which people and teams. respond, medical educators might want Results to consider avenues for training learners Method Elevated stress levels can impede in stress management. More research The Sciences Citation Index, Medline, performance on tasks that require and Psychinfo were used to search for is needed to fully understand the divided attention, working memory, articles up to and including 2008. The contributions of personal factors such as search terms were stress/tension/arousal/ retrieval of information from memory, coping style and locus of control, as well anxiety/cortisol/threat, cognition/skills/ and decision making. These effects as the relationship of perceptions of memory/attention/problem solving/ appear to be determined by the stress to issues such as fatigue. decision making/performance, stress individual’s appraisal of the demands and Acad Med. 2009;84(10 Suppl):S25–S33. reduction/stress exposure/stress resources of a situation, the relationship management/stress inoculation, and between the stressor and the task, and health professionals/medicine/medical factors such as coping styles, locus of students/residents/physicians/teams. The control, and social supports.

Training to become a physician and the carry out necessary clinical procedures. If scope of this paper. The effects of stress on practice of medicine are activities that stress, in addition to its impact on well- procedural and motor skills are also beyond contain a significant amount of stress for being, impairs learning and medical the scope of this paper. individuals. Common sources of stress decision making, patient care and safety include treating critically ill and rapidly could be jeopardized. Understanding the Method deteriorating patients, performing high- extent to which stress affects clinical intensity procedures, functioning while performance will allow us to effectively Although relatively little research has sleep deprived, inadequate personal time, target technological and educational been conducted on this topic in the disruptions in social support, licensing interventions where they are most likely domain of medical education, there is a examinations, and conflicts between to be of benefit. The aim of this paper is substantial body of literature from the 1–7 clinical and educational responsibilities. to review representative research focused psychological domain addressing the These stressors have significant effects on on both the positive and negative effects effects of stress on cognitive abilities and 1,5,7–10 11–12 individuals. Most, but not all, of acute stressors on the cognitive performance. The purpose of this review researchers observe that approximately is to summarize the body of literature on abilities (i.e., memory, attention, 25% to 35% of medical trainees report the effects of acute stressors, to discuss reasoning, problem solving) of symptoms of anxiety and/or depression in the implications of these findings to individuals and teams. The literature in response to the stressors they encounter. health professions education and several domains of research will be practice, and to discuss some promising examined for the purpose of generating a Despite the documented link between job methods aimed at reducing the negative stress and mental health,13 there is little coherent and comprehensive effects of acute stressors on performance. research on the impact of stress on representation of the effects of stress in clinical performance.14 It is important to clinical practice and of mechanisms for The Sciences Citation Index, Expanded understand how stress affects clinicians’ addressing these effects. The explicit (containing the Sciences Citation Index, or trainees’ abilities to process clinical focus is on what happens during acutely the Social Sciences Citation Index, and information, remember this information, stressful events, because this is an area of the Arts and Humanities Citation Index), make decisions, function as teams, and inquiry that has received relatively little Medline, and Psychinfo were used to systematic inquiry in health professions search for articles up to and including education. Links to the broader literature 2008. The following searches were Correspondence: Vicki R. LeBlanc, PhD, Wilson regarding topics such as sleep deprivation conducted: (stress OR tension OR arousal Centre, University of Toronto, 200 Elizabeth Street, 1ES-565, Toronto, ON, Canada M5G 2C4; e-mail: and the potential effects on suicide, divorce, OR anxiety OR cortisol OR threat) AND ([email protected]). and other health indicators are beyond the (cognition OR skills OR memory OR

Academic Medicine, Vol. 84, No. 10 / October 2009 Supplement S25 Review Paper attention OR problem solving OR situation in a two-stage process. In a first Results decision making OR team performance stage of appraisal, they assess the Stress and performance OR performance), (stress reduction OR demands required of the situation to stress exposure OR stress management reach or maintain the desirable goal. In a To date, there has been relatively little OR stress inoculation), and (stress) AND second stage of appraisal, they assess the research looking at the specific effects of (health professionals OR medicine OR resources—personal and stress on the performance of health medical students OR residents OR environmental—available to meet the professionals. Of the research that does physicians OR teams). The search was perceived demands of the situation. exist, the findings are ambiguous. Some studies have shown impaired limited to papers in English from all When the resources are assessed as being performance under acutely stressful developed countries. Secondary sufficient to meet the demands, the conditions,23,24 while others have shown references were selected from primary situation is assessed as a challenge and a improved performance.25 The paucity of papers. The use of the search terms positive psychological state of “eustress” research and seemingly conflicting results revealed more than 1,000 peer-reviewed ensues.19 When the demands are assessed have allowed the development of publications, including the bulk of the as outweighing the resources of the somewhat naïve perceptions by health literature which addresses chronic stress individual, the situation is assessed as a and anxiety, as well as clinical levels of professionals and educators regarding the threat.19 A negative psychological anxiety. A review of the abstract of each effects of stress on performance. Beliefs response of “distress” ensues, including a article to identify those that discussed that stress can enhance learning (“you variety of affective states (the most acute stressors led to the selection of the learn better under the gun”) coexist common being anxiety). 99 publications cited in this review. closely with beliefs that learning is optimized in conditions that are free of After either a challenge or threat anxiety and stress. As a community, the What is stress? appraisal, the sympathetic nervous risk we face by not fully understanding system (SNS) will be activated if an active The term “stress” was coined in the 1930s the effect of stress is that we could fail to 15 by the endocrinologist Hans Selye. After response is required. This results in the adequately prepare individuals to exposing animals to various noxious very rapid increase, over a period of function in emergency or crisis situations 20 stimuli, he found that they all showed a seconds, of heart and respiration rates. or, even worse, impair learning and similar reaction that he labeled the In addition to the SNS response, a threat acquisition of these skills. General Adaptation Syndrome (GAS). appraisal leads to the activation of the The GAS contains three phases: an alarm hypothalamic–pituitary–adrenal (HPA) The effects of stress on performance have phase in which an organism identifies a 21 axis. The activation of the HPA axis been investigated quite extensively in stressor or a threat and the body mounts results in the increased release of the domains such as psychology, high-risk an alarm response, a resistance phase in hormone cortisol in the blood which is industries (nuclear power plants, which the body attempts to adapt and then diffused to the saliva over a period aviation, law enforcement), and cope with the stressor, and an exhaustion of minutes. This increase in cortisol levels psychoneuroendocrinology. In all of phase in which the resources are influences areas of the brain that are these domains, research into the effect of eventually depleted in the face of heavily involved in cognitive processes: stress presents many challenges. Most sustained stress and the body is unable to the amygdala, hippocampus, and important, it is difficult to predict when maintain normal function. The prefrontal cortex.21,22 exhaustion phase can lead to long-term acutely stressful events (crises, damage to the adrenal glands and the emergencies) will occur in real life, and it Thus, an individual’s response (subjective is unethical to manipulate stressors immune system, leading to depression, and physiological) to demands that cardiovascular problems, and other during real-world events. As such, threaten an important goal is highly mental issues.16,17 While the latter two researchers have developed various dependent on that individual’s stages of the GAS have been instrumental approaches to investigate the effects of perception of the demands and of his or in understanding the effects of chronic stress, from retrospective reviews of her resources available to meet those stress, the first stage (the alarm phase) is critical nuclear or aviation incidents, to demands. Any factor that increases the most pertinent to the study of high-fidelity simulations of military, performance under acute stressors and perceived demands of a task or decreases nuclear, and aviation operations, to will be the main focus of this review. the perceived resources to meet those interventional studies in which the demands increases the likelihood of a physiological processes of stress responses The initial stress response is theorized to distress response. Socioevaluative (elevated heart rate and cortisol levels) result from the interaction of the stressors (where others could negatively are recreated with the administration of demands placed by an individual’s judge performance) and uncontrollable pharmacological agents. Although each environment and that person’s resources stressors are the most likely to provoke particular method has recognized to meet the demands. It is heavily a distress response.21 In the context of limitations in the conclusions that can be influenced by a person’s assessment of this paper, the terms “stress” and drawn from its results, these various the situation.18,19 When individuals “stress response” will be used when methods converge to allow us to draw perceive a real or anticipated challenge to referring to the distress response that some conclusions regarding the effects of their primary goals (i.e., passing a ensues once a situation is assessed as a stress on attention, memory, decision licensing exam, keeping a patient stable threat to maintaining or achieving a making, and, to some extent, group during surgery), they appraise the primary goal. performance.

S26 Academic Medicine, Vol. 84, No. 10 / October 2009 Supplement Review Paper

Stress and attention. In their everyday disruptive to performance when the gathered from multiple sources (clinical activities, individuals are bombarded stress results from factors peripheral to monitors, other team members), to keep with all sorts of perceptual information. the task and may facilitate performance previously learned information in mind However, our ability to process this when the task being performed is the (patient drug allergies), and to information is limited. Under stressful source of the stress response. manipulate this information to reach conditions, the cognitive system becomes clinical decisions. Elevated stress levels overloaded, decreasing a person’s Although there are conflicting findings and cortisol levels appear to impair attentional resources.26 regarding the effects of stress on selective working memory.37,38 Elzinga and attention, there is consistent evidence Roelofs39 observed that individuals who The effects of this stress-related reduction that divided attention tasks, those that exhibited a threat response (cortisol and in attentional resources on selective require the integration of information SNS responses) to a public speaking task attention remain unclear. Selective from several sources, are vulnerable to were impaired on a task of working attention is the process that allows us to the effects of stress and elevated cortisol memory. In contrast, individuals who focus on those stimuli that are relevant to levels.26,30,31 For the emergency medicine exhibited a challenge response (SNS us, preventing the cognitive processes trainee who is leading a cardiac arrest arousal but not cortisol elevation) were from becoming overloaded with team, and who must process information not impaired on the working memory information. It is the filter that from multiple sources, performance is tasks. Similarly, Beilock and Carr40 have determines what information is likely to be impaired under stress. In observed that under pressure, individuals processed and what is ignored. Some these conditions, in which there are demonstrate performance decrements in researchers argue that selective attention multiple targets, performance will be solving a mathematical problem: a task is facilitated under stressful conditions impaired because one target will be that is thought to rely heavily on working and that the limited resources are selectively attended to, to the exclusion of memory. Working memory impairments allocated to information that is relevant other relevant targets. Tunnel vision are especially likely when the task load is to the task being completed rather than (extremely narrow perspective) and high22,37 and when performance is to information that is irrelevant. As stress premature closure (tendency to stop assessed during the stressful event itself.39 increases and attention becomes more considering other possible diagnoses after selective, there is a growing exclusion of a diagnosis is reached) are more likely to Memory consolidation. Memory information that is irrelevant to the task occur.32 consolidation is the process by which new at hand, a process called cue utilization and fragile memories are rendered into reduction by.26 As such, stress will be Stress and memory. Memory—the more stable and permanent memories.41 beneficial when a task requires the ability to store, retain, and subsequently Elevated stress responses, especially if exclusive focusing on target information. retrieve information—is critical to every they lead to increased cortisol levels, have Alternatively, there is also some evidence aspect of medical training and clinical been associated with the enhancement of that the reduction of attentional practice. There is a general belief, based memory consolidation.22,35,42 resources under stress may result in a on subjective experience, that stress Abercrombie and colleagues43 asked decreased ability to filter out irrelevant influences memory. Many clinicians participants to recall words they had information from relevant information.27 anecdotally report that some experiences learned two days earlier, immediately Hence, stress can also lead to increased during their training or clinical practice after being administered exogenous distractibility of the individual.28 seem as if they will be remembered for a cortisol. The participants who had been lifetime, whereas other events seem to administered moderate doses of cortisol An explanation of the conflicting findings have been forgotten (or never encoded) (levels that mimic those observed during regarding the effects of stress on selective because of the stress surrounding the moderate stressors such as final attention may lie in the relationship event. A brief survey of the literature can examinations) performed better on a test between a stressor and the task being also be confusing, with some studies of word recognition. The effect is performed. When feeling anxious, showing that stress impairs memory33,34 especially strong for materials that are people’s attention is biased towards and others showing that stress enhances arousing or emotionally laden rather threat-related information.29 Selective memory.35,36 However, a close review of than neutral information.22,36,44 In attention will be focused on those aspects the literature reveals that the effects of addition, the facilitation of memory of a stressful situation that induce the stress depend on the memory phase that consolidation processes only occurs at stress response. As such, if the task being is activated during stressful situations.22 moderate stress levels; extremely high performed is integrally related to the Stress responses and increases in cortisol levels of HPA axis activation will impair source of the stress (resuscitating a levels differentially influence three memory consolidation.43,45 patient), then selective attention should components of memory: working be narrowed towards the task itself. memory, memory consolidation, and the Therefore, the general belief that However, if the source of stress is retrieval of information from memory. individuals learn better from stressful peripheral to the task being performed events is supported by the research, but (i.e., loud noises, disruptive team Working memory. Working memory with an important caveat. Information members), then attention will be focused consists of the capacity to store and from a to-be-remembered event will be on the source of the stress, to the manipulate information for brief periods retained quite well if it is that event that increasing exclusion of information of time.37 This is the process that allows causes the stress response in the related to the task itself. As such, the the team leader in a cardiac arrest to individual. If the stress is caused by restriction in selective attention may be simultaneously keep track of information something that is peripheral to the to-be-

Academic Medicine, Vol. 84, No. 10 / October 2009 Supplement S27 Review Paper remembered information, the memory are either unaffected or making on naturalistic tasks under stress, consolidation of that information will not enhanced.47,51 This effect seems to be researchers had participants identify be enhanced.46 For example, a surgery limited to the free recall of information unknown contacts that appeared on resident who feels stressed during surgery (when no cues are given to assist in the naval radar screens. These participants because of an intimidating or abusive retrieval of information) and does not were familiar with the task. The results staff surgeon may develop a strong seem to impair recognition memory demonstrated that experienced memory of the actions of the staff (remembering previously presented participants who used hypervigilant surgeon, but the resident’s memory of the information when it is offered again).33,34 decision-making strategies made a greater patient and of the surgery itself will likely number of accurate identifications than Consistent with these laboratory-based not be enhanced. Similarly, a trainee who those who used vigilant decision-making findings, LeBlanc and colleagues24 have takes part in simulation sessions in which strategies.54 More research is required to observed that skilled paramedics the primary source of stress is a compare vigilant and hypervigilant demonstrate significant impairments in socioevaluative one (being observed and decision making in novices exposed to the ability to solve drug calculation assessed by a faculty member or fear of stressful situations. problems (a task that depends both on “losing face” in front of peers) will the retrieval of mathematical formulas remember those aspects of the simulation Stress and group performance. The from memory and in the storage and session. However, the trainee’s memory complex and dynamic nature of the manipulation of information in working of the simulated scenario and associated medical environment often requires memory) immediately after working learning points will not be enhanced. For teamwork. In crisis or emergency through highly stressful simulated trainees to have enhanced consolidation situations, individuals are required to scenarios. Thus, although a stressful of the central details of a clinical case and, work together in a coordinated fashion to learning episode may consolidate well as a result, better learning, the case itself make decisions about patient care.56 into memory, the retrieval of previously needs to be the source of the stress Surprisingly, relatively little is known learned material is less efficient under response. regarding the effects of stress on team high levels of acute stress. work, group decision making, or Memory retrieval. In contrast to the performance. Much of the research on Stress and decision making. When facilitating effects on memory team performance under stress is based stressed or anxious, individuals consolidation, stress leads to on retrospective reviews of aviation demonstrate an increased use of cognitive impairments in the retrieval of memories. incidents or on observations of team heuristics52 and of decision-making In laboratory studies, elevated cortisol work solely during crises or acute events. strategies that are considered suboptimal. responses to psychosocial stressors (i.e., Vigilant decision making, considered public speaking) led to impairments on The specific effects of stress on teams optimal by many, consists of a systematic tasks that required participants to have been investigated with respect to and organized information search, a remember previously learned two aspects of performance: team thorough consideration of all available information47–49 and to remember prior perspective and centrality of authority. alternatives, the devotion of sufficient autobiographical events.50 As with Two groups of researchers have observed time to evaluate each alternative and the working memory, it seems that the that increased stress leads to a loss of review of data before making a decision. impairment in memory retrieval occurs team perspective and decreased team In contrast, hypervigilant decision when individuals have a threat response performance on military decision- making is considered an impulsive and to stressors (and the accompanying making tasks.56,57 This decrease in team disorganized pattern of decision making. cortisol response), with no impairments perspective is thought to result from the It consists of a nonsystematic or selective occurring in individuals who have a attentional narrowing that occurs in search for information, the consideration challenge response to a stressor. In a individuals under stress. Although these of only a limited set of alternatives, the study by Buchanan and colleagues,33 two studies provide some insights into rapid evaluation of the data, and the participants learned a list of words. One the effects of stress and team selection of a solution without hour after learning the list of words, the performance, these findings have not reappraisal. The use of hypervigilant participants were exposed to a stressor been confirmed or replicated with studies decision making when stressed has been (immersion of hand in cold water) and looking at different tasks, group associated with poor performance on then were immediately asked to recall the composition, or stressors. As for the laboratory-based tasks.32,53 previously learned list of words. The effects of stress on the centrality of participants who exhibited a threat However, hypervigilant decision-making authority, the results are conflicting. response to the stressor (elevated cortisol strategies may represent adaptive Some researchers have observed a responses and elevated SNS arousal) responses to naturalistic task demands.54 centralization of authority under stress, performed worse on the delayed recall In naturalistic tasks, decisions need to be where the control and decision making test of the words. In comparison, those made under time pressure, the data are become concentrated in the high levels of participants who exhibited a challenge ambiguous and/or conflicting, and hierarchy.58 In this case, team leaders response (SNS arousal without decision makers are likely familiar with were less receptive to input from other corresponding increase in cortisol levels) the tasks. In such conditions, it is argued members of the team. In contrast, other performed as well as participants in a that decision makers can use their researchers have observed team members control group. At lower levels of experience to identify meaningful data becoming more receptive to information subjective stress, tasks that are dependent and to generate reasonable options.55 In provided by other team members. During on the retrieval of information from one of the few studies looking at decision controlled laboratory decision-making

S28 Academic Medicine, Vol. 84, No. 10 / October 2009 Supplement Review Paper tasks, Driskell and Salas59 observed that significant individual differences in stress control are associated with depression in their participants were more receptive to responses and performance. The most paramedics.76 Ambulance personnel input from teammates when making important moderators of stress responses reveal significantly more externality, thus decisions in stressful conditions and performance under stress are less perceived control over what happens compared with low-stress conditions. reviewed in this section. in their lives, which may make them more predisposed to the effects of The large part of research looking at Coping styles. A potentially important stress.77 stress and team performance has been mediating factor in the appraisal of a aimed towards understanding what situation as a challenge or a threat is an Social support. There is a substantial characteristics of the team lead to optimal individual’s coping style: the thoughts body of literature showing that performance during high-demand and behaviors used to manage both the individuals who have access to situations.60 A number of characteristics internal and external demands of psychological support in demanding of effective team performance in stressful situations that are appraised as situations such as stressful employment events have been identified, such as the stressful.66,67 Although there is some or facing chronic stressors seem to be in ability to adapt to changing situations, debate regarding the classification of better health compared with individuals effective communication, and effective coping strategies, there are three main without significant support. There is resource allocation, as well as the categories of coping styles.66,68 Problem- correlational evidence for beneficial presence of situation awareness and clear focused coping consists of addressing the effects of social support on endocrine and leadership. These characteristics seem to problem causing the distress (i.e., having immune system parameters during depend on the presence of implicit a plan of action, concentrating on the stressful periods of life.78 During acute coordination.60–63 Implicit coordination next step). Emotion-focused coping is stressors, the presence of social support is occurs when teams are able to predict the aimed at reducing or managing the associated with decreased cortisol needs of the task at hand and anticipate emotional distress that is associated with responses,78 cardiovascular responses,79 the actions of other team members in the situation (i.e., seeking emotional and subjective stress responses.80 order to adjust their behavior support, focusing on and venting of accordingly. This implicit coordination emotions). Avoidance coping is aimed at depends on a shared mental model, a seeking to avoid or distract oneself from Discussion common understanding of the situation the situation (i.e., seeking out social Although this critical review brings to and tasks at hand.60 These mental diversion, engaging in distracting tasks). light the fact that substantially more models, when accurate, allow people to Problem-focused coping styles seem to be research needs to be conducted to gain a appropriately understand phenomena, more effective in controllable situations deeper understanding of stress responses draw inferences, make predictions, and in which individuals can manipulate the and their impact on the performance of decide what actions to take.60,64 Shared stressors,69 and emotion-focused coping individuals and teams, some general mental models are essential to implicit styles seem to be effective when dealing patterns are emerging from the literature. coordination because they allow with stressors that are of brief duration First, stress is highly subjective. What is members of a team to generate and that cannot be controlled.70–72 distress for one is eustress for another predictions about tasks and team Avoidance coping styles, although and a nonevent for a third. Second, it demands in the absence of associated with decreased subjective seems that the relationship between a communication between team stress levels, have been associated with stressor and a task is important in members.60 increased cortisol responses.69 As such, determining whether performance will be they may be detrimental to performance enhanced or impaired. When a stressor is Although this body of research describes under stressful circumstances. contingent to the task being performed, a the underlying processes of effective person’s cognitive resources will be teams, it does not shed light into such Control. A second potentially important focused on that task, and certain aspects things as the factors that enhance or mediating factor is an individual’s locus of performance may be facilitated. In impair the development of shared mental of control: the extent to which that contrast, stressors that are peripheral to a models or of the forces that influence or individual perceives that he or she has task seem to draw cognitive resources shape a team’s coordination during high- control over a given situation. Individuals away from the task being performed, and acuity events.65 As such, substantially with an internal locus of control are those performance is more likely to be impaired. more research is required to understand individuals with the perceived feeling of These have important implications for how stress affects team interactions and being able to control events in their lives. health professions education and for how how team dynamics adapt to stressful These individuals are likely to develop a we prepare trainees to perform tasks under events, as well as to identify the factors of positive outcome expectancy and, stressful conditions. the environment that erode team consequently, lessened stress responses coordination. and performance impairments in acutely First, educators wishing to design stressful situations.73 Individuals who, in stressful situations in the hopes of Factors that affect stress response and the face of crisis, manage to retain a belief enhancing memory consolidation need to performance that they can control outcomes have been ensure that the source of the stress is While the review of the literature above found to manage the experience far more intrinsically linked to the information presents some general trends and effectively than individuals who believe that is to be learned. If the source of stress patterns regarding the effects of stress on they are controlled by external forces.74,75 is peripheral to the task (i.e., having to performance, researchers have observed For example, higher levels of external perform in front of a group, or with

Academic Medicine, Vol. 84, No. 10 / October 2009 Supplement S29 Review Paper disruptive teammates, loud noises, or practicing newly acquired skills after the typically tailored to anesthesia crises or intimidating or challenging staff), then skill has been acquired to a level of cardiac arrests, and they generally center learning will not be enhanced. proficiency.81 Overlearning can be on the principles of situation awareness, effective in preparing trainees for establishment of leadership, clarity of The second important implication of performance under stressful conditions roles, and personnel and resource these findings is that training for high- because of several factors.72 First, management.86 Similarly, MET training acuity events needs to go beyond training complex tasks are more likely to be focuses on improving the organization, that is oriented solely towards the impaired under stressful conditions than efficiency, and reliability of crises team acquisition of skills and knowledge. Such simple tasks.22,34 Overlearning can responses by emphasizing the training will be insufficient to prepare contribute to the simplification of reinforcement of organizational aspects trainees to perform optimally under complex task and can thus make them of team performance, such as assuming high-stress situations. In addition to this less vulnerable to stress.72 Second, designated roles independently, skills-based and knowledge-based overlearning can lead to the completing tasks or goals assigned to training, training programs should automatization of skills so that they can each role, and directed communication.83 supplement these with interventions be performed with little demand on In the majority of cases, this form of aimed at developing the trainees’ ability cognitive processes.82 This frees up training consists of didactic lectures, to cope with and withstand important cognitive resources that can then be followed by hands-on practice at stressors. Promising methods of training applied to coping with the stress response resolving medical crises with feedback. for stressful events are discussed in the or with other aspects of performance. Although the bulk of team training is following section. Finally, when tasks are overlearned and conducted with high-fidelity Finally, the findings in this review bring well drilled into trainees’ repertoire, this computerized mannequins placed in to light the fact that more research is can increase their sense of control in realistic clinical scenarios, some groups needed to gain a deeper understanding of performing the task.72,82 use vignettes, role modeling of ideal the effects of stress, particularly in terms behaviors by video, and role playing.88 of attentional processes, decision making, Although overlearning has the potential There is accumulating evidence and group performance. Furthermore, to be an effective method of preparing indicating that this type of training research looking at reactions to stress trainees for performance under acutely improves team performance in simulated requires careful measurements to stressful conditions, its application can crises,89 and there is some preliminary determine the level of stress, in particular have significant drawbacks if it is not research indicating that team training can distress, that is present in each individual carefully designed and executed. One of improve team performance at the participant. Mere immersion in a the more important drawbacks is that bedside.88 situation is insufficient because some are overlearning can limit the individual’s not stressed by that situation. Further, ability to demonstrate flexibility in his or Stress management interventions surface behavioral characteristics are her response and to adapt to changing insufficient; autonomic reactivity in the conditions.72,82 Preparatory information. Based on the absence of cortisol elevations would findings from medical studies that imply eustress, not distress, and seems to Team training. Recognizing that sound preparatory information can lessen have a decidedly different impact on the medical and technical abilities, although negative reactions in patients about to individual’s performance. necessary, are not sufficient to ensure undergo stressful clinical procedures, competent team performance in crises, there is growing interest in the use of Training for performance during many educators have developed team preparatory information for reducing stressful events training interventions.83–86 The overall stress reactions and enhancing A number of approaches have been goal of team training is to foster the performance in nonclinical settings.90 developed in an attempt to optimize development of accurate shared mental Preparatory information is hypothesized performance during stressful events. models of patient care in high-stress to be effective by rendering the stressor 82,87 These approaches can be categorized as situations. Several models of team and the task less novel and more familiar, either skills-based training or as stress training have been developed and applied and by enhancing the sense of behavioral management interventions. In skills- in the aviation and military or cognitive control over an aversive based training, the emphasis is on environments, such as cross-training, event.72,90 The effectiveness of providing individuals or teams with the perceptual contrast training, team preparatory information lies not solely on specific skills required during a crisis. In coordination training, team self- a detailed description of an upcoming stress management interventions, the correction training, and guided error stressful event but also in providing 87 emphasis is placed on modifying the training. The model most widely information about prescriptive ways in individual’s appraisal of a potentially applied in health professions is team which individuals can cope with the stressful situation. Promising examples of coordination training, such as crisis stressor and its effects.72 A each approach are described in this resource management (CRM) training comprehensive preparatory information section. and medical emergency team (MET) strategy addresses how the person is likely training.83,88 Originating in the field of to feel in a stressful setting (sensory Skills-based training aviation, CRM training recognizes that information), describes the events that individual and team performance can be are likely to occur during the transition Overlearning. Overlearning training significantly degraded in crisis situations. from normal to stressful conditions consists of requiring trainees to keep Although approaches vary, they are (procedural information), and provides

S30 Academic Medicine, Vol. 84, No. 10 / October 2009 Supplement Review Paper information on how the person can capacity to respond effectively to stressful coping styles, locus of control, and social counter the undesired effects of stress situations. This phase is focused on supports. However, more research is (instrumental information). training the individual to maintain an required in this area to fully understand awareness of stress reactions and to the contributions of these factors to Although the research looking into the invoke appropriate skills to reduce stress. performance under stress and to effectiveness of this approach to enhance These skills consist of cognitive effectively prepare trainees to perform performance in stressful environments is restructuring techniques aimed at under acutely stressful conditions. limited, the early findings are regulating negative emotions and Eventually, it will be useful to overlay the promising.91 In a study with military thoughts and of relaxation techniques to stress and stress management literature personnel, Inzana and colleagues90 increase control over physiological with other timely topics in medical observed that presentation of preparatory responses. The third and final phase education such as fatigue and burnout. information reduced subjective anxiety consists of the application phase. The and improved performance accuracy on coping skills are applied in increasingly Naval decision making tasks. The stressful conditions that approximate the Acknowledgments beneficial effects of the intervention were real-world stressor environment. The author reports no conflicts of interest, observed in both a high stress and a including financial interests and relationships normal stress condition. and affiliations relevant to the subject of this Stress inoculation training has been manuscript. Although the effectiveness of preparatory found to be effective in reducing general information on team performance has yet state anxiety and performance anxiety to be investigated, a promising platform (anxiety specific to the skills being References is brought to mind with the recent work addressed in the training) and in 1 Toews JA, Lockyer JM, Dobson DJG, in the area of team communication. enhancing performance under stress.95–98 Brownell AK. Stress among residents, medical Lingard and colleagues92 have shown that Stress inoculation training seems to be students, and graduate science (MSc/PhD) students. Acad Med. 1993;68(10 suppl):S46– a preoperatory briefing with completion effective when run with groups of 8 to 10 S48. of a checklist led to a reduction in participants, and it can be implemented 2 Butterfield PS. The stress of residency: A communication failures, an increase in successfully without an inordinate review of the literature. Arch Intern Med. the identification of problems and number of training sessions. Its 1988;148:1428–1435. effectiveness does not seem to be 3 Kain ZN, Chan K-M, Katz JD, et al. ambiguities, and modifications in the Anesthesiologists and acute perioperative plan of how the case would proceed. restricted to the laboratory setting, stress: A cohort study. Anesth Analg. 2002;95: Although this intervention did not suggesting that it can be effective in 177–183. specifically target team performance applied settings such as health 4 Linzer M, Gerrity M, Douglas JA, McMurray during high-stress situations, this sort of professions education.94 Finally, the JE, Williams ES, Konrad TR. Physician stress: Results from the Physician Worklife Study. intervention holds promise. It could be beneficial effects of stress inoculation Stress Health. 2002;18:37–42. further examined to determine whether training can generalize to novel stress 5 McCue JD, Sachs CL. A stress management its implementation reduces stress levels, conditions and novel tasks,99 which is workshop improves residents’ coping skills. increases shared understanding of the crucial for any applied area in which the Arch Intern Med. 1991;151:2273–2277. conditions of real-life environments are 6 Michie S, Williams S. Reducing work related case, and, in doing so, enhances the psychological ill health and sickness absence: implicit coordination and team often dynamic, ambiguous, and A systematic literature review. Occup Environ performance during crisis situations. emergent. It should be noted, however, Med. 2003;60:3–9. that further research needs to be 7 Reuben DB. Depressive symptoms in medical Stress inoculation training. One conducted regarding the extent to which house officers: Effects of level of training and work rotation. 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