Performance Under Pressure part 2

hallo guys today in this class we well lern about Performance Under Pressure part 2so let’s stat this class

Performance Under Pressure – The Full Course includes all the three courses already published:

  1. The Right Attitude
  2. Taking Action
  3. Effective Human Interactions

1. The Performance Under Pressure – The Right Attitude section helps you recognize the events and situations that cause you to feel pressure. It explains how you can understand your reaction to pressure, and how excessive stress can impair your performance.

Finally, it covers the principles for managing your attitude so you stay in control and maintain a success-oriented mentality. Because, meeting high-pressure challenges is an opportunity for you to excel and build your reputation as someone who can be counted on.

Professionals and all who want to develop their abilities to manage the stress that comes with working under pressure and anyone who wants to develop or refine their skills for performing under pressure.

After completing this topic, you should be able to:

  • identify the factors that in a situation are likely to trigger pressure,
  • recognize how your response to pressure can impair your performance,
  • conduct a stress profile, and
  • manage your attitude in pressurized situations.

The section includes video lectures, quizzes, examples and exercises and a small optional course project. All should take you not more than 2 hours to finish.

2. The second part of a series of three courses on Performance Under Pressure and focuses on Taking Action. And, in this course, you are going to learn not only how to take action under pressure, but also how to avoid over-thinking and over-confidence, and understand what exactly the challenge is.

Acting effectively in high-pressure situations is not easy. Over-confidence can lead to poor judgment, and over-thinking the situation can lead to paralysis. Also, your perception may become clouded by negative thoughts and emotions in times of pressure. But it’s exactly at these times that you need to perceive the challenges most clearly so that you can set appropriate goals and take effective action to achieve them.

This course sets out some principles to help you avoid the dangers of overconfidence and overthinking, which can impair your performance when under pressure. It then teaches a technique for clarifying your perceptions in such situations and creating an action plan to optimize your performance under pressure.

Professionals who want to develop their abilities to manage the stress that comes with working under pressure, and those who want to develop or refine their skills for performing under pressure will benefit from this course.

After completing this section, you will be able to:

  • avoid over-analysis and over-confidence in high-pressure situations,
  • understand the challenge in a high-pressure situation from emotional reactions,
  • manage automatic thoughts to optimize perceptions in high-pressure situations,
  • use appropriate steps in the process of taking action in a high-pressure situation, and
  • take action in pressure situations to match every challenge.

3. The third and last part of a series of three courses on Performance Under Pressure and focuses on Effective Human Interactions. And, in this course, you are going to learn to prevent and deal with negative pressure, manage your reactions, deal with colleagues and stressful situations.

High-pressure environments can be hard on professional relationships. You can so easily get caught up with a major project or looming deadline that your interpersonal skills slip. Under pressure, you may start to make instinctive emotional reactions as your awareness of others’ feelings fades.

This course helps you develop skills you need to recognize your personal reaction to pressure and how it impacts your relationships with others. It shows how you can consciously control your interpersonal reactions when under pressure and how to avoid unnecessary tensions.

And it details a step-by-step process you can use to stay in control when you’re faced with a high-pressure interaction. This all enables you to recognize the importance of professional relationships, and it helps you to stay in control and make the right moves when you’re performing with others under pressure.

Professionals who want to develop their abilities to manage the stress that comes with working under pressure and anyone who wants to develop or refine their skills for performing under pressure.

After completing this course you will be able to:

  • understand negative reactions to pressure in the workplace and not only
  • use a step-by-step approach for managing your reactions in pressure situations
  • deal with a colleague, a friend or anyone else under pressure
  • be prepared to manage potentially stressful interactions

This course includes video lectures, examples, quizzes and some learning support documents, and it will take you not more than 3 hours to finish. And, as usual you have the 30 days money back guarantee, no question asked.

Now, if this is something that will help you, go ahead and press that “Take This Course” button. And, see you inside the course!

Who this course is for:

  • this course is for all who want to develop their abilities to manage the stress that comes with working under pressure and anyone who wants to develop or refine their skills for performing under pressure

What you’ll learn

  • Identify factors in a situation likely to trigger pressure, recognize how your response to pressure can impair your performance
  • Conduct a stress profile and recognize how to manage your attitude in pressurized situations
  • Avoid overanalysis and overconfidence in high-pressure situations, understand the challenge in a high-pressure situation from emotional reactions
  • Manage your automatic thoughts to optimize perceptions in high-pressure situations, follow appropriate steps in the process of taking action
  • Understand negative reactions to pressure in the workplace and not only, use a step-by-step approach for managing your reactions in pressure situations
  • Deal with a colleague, a friend or anyone else under pressure and be prepared to manage potentially stressful interactions
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Optimizing Performance

Emergency medicine is an inherently stressful pursuit. In other professions, the optimal approach might be to redesign activities to minimize stress, thus maximizing performance. To the extent that we can manage stressors, such as ensuring the correct equipment is always available and trying to manage bed block, we absolutely should, but for the most part, we will never be able to separate emergency medicine from intense performance pressure. Therefore, we need strategies to help us manage stress and ensure that we can perform optimally under pressure.

Watching our peers perform at incredibly high levels under stress, it can seem like some people are just naturals. It is easy to get the impression that these individuals simply have some skill that you don’t. Although we may have different starting points, stress management – like all other skills – can be learned. You can get better. (If you have never read Mindset by Carol Dweck I would highly recommend it.) Jason Brooks has interviewed a large number of these “high performing doctors”, and he tells us that the secret to your best performance as a physician is closer than you might think.

Before the stressor: Stress preparation

High level musicians and athletes have been using stress preparation techniques with great success for a long time. However, it is obvious that these techniques don’t stand alone. Michael Jordan doesn’t sink a free throw just because of his breathing technique. First, he learned the proper shooting technique, then practiced it thousands of times. But with a game on the line, breathing was one component of ensuring that he was able to manage stress and reproduce the shooting technique he had spent his life perfecting. Similarly, these stress management techniques will not make you a great resuscitationist. You must first master the craft; put in your time practicing. These techniques are to ensure that you are able to perform at the very high level you are capable of, even in the worst situations.

Much like you have to practice your technical skills, the skills discussed here also require practice. You can’t expect to step into a horrible resuscitation and use tactical breathing or centering techniques for the first time. They just won’t work for you. They require practice so they will be available to you when you need them.

Hope: If you are liking the class, then stay tuned, keep learning in the class, then you know.

General Health

It is essential to prepare your tools. Much like a mechanic must take time to keep his tools in optimal shape, so must medical personnel maintain their key tools: their minds and bodies. Exercise and adequate sleep are essential. (Grossman and Christensen 2004) Trying to address personal stressors like relationship issues before coming to work is difficult but important. Similarly, we must be aware of the effects of substance use, whether alcohol, caffeine, or drugs, on our overall health and performance. (Whitelock and Asken 2012)

A person too busy to take care of his health is like a mechanic too busy to take are of his tools

Stress inoculation training (aka stress exposure training)

Stress inoculation is a form of cognitive behavioural therapy that involves three steps. The first step is education or cognitive preparation, focusing on understanding the physiologic and psychological impacts of stress. The second step is skill acquisition and rehearsal, focusing on developing and practicing arousal control or stress reduction techniques. The skills learned are cognitive restructuring techniques aimed at controlling negative thoughts and relaxation techniques aimed at increasing control over the physiologic responses to stress. (Both problem based and emotion based coping mechanisms). The final phase is application of these skills in real world or simulated environments, with reflection and feedback. (Petrosoniak and Hicks 2013; Meicheribaum and Novaco 1985; Whitelock and Asken 2012; LeBlanc 2009; Saunders et al. 1996)

Although there are numerous well described stress reduction techniques (described further below), one point that is frequently emphasized in stress inoculation therapy is the need to draw on personal experience and expertise. (Meicheribaum and Novaco 1985; Meichenbaum 1985) The idea is to think through one’s most stressful encounters and consider the things that one did or could have done to manage the stress. In emergency medicine, we have the tremendous benefit of colleagues with a wealth of experience in managing stress. I would also try to draw on their expertise. Furthermore, no single coping strategy is universally effective. The object of stress inoculation training is to equip individuals with a variety of coping strategies that can be mixed and matched. (Meichenbaum 1985)

It should also be emphasized that learning to manage stress is a separate task from learning the skills of resuscitation. In can be confusing and counterproductive to introduce stress into sessions where clinical skills are supposed to be learned. Remember, stress can impair memory. Ideally, clinical skills are mastered first, and then stress management is taught as a separate skill. (Driskell and Salas 2013)

In a number of fields outside of medicine, stress inoculation therapy has been demonstrated to reduce the subjective sensation as well as objective markers of anxiety, decreased performance anxiety, and enhance performance under stress. (Driskell and Salas 2013; Gaab et al. 2006; Gaab et al. 2003; Hammerfald et al. 2006; Meichenbaum 1985; Saunders et al. 1996) Stress inoculation training appears to have value even after a limited number of training sessions, and the education seems to be generalizable to novel settings. (Petrosoniak and Hicks 2013; J. E. Driskell, Johnston, and Salas 2001; Grossman and Christensen 2004) Stress inoculation training has also be successful with a variety of different instructors, from trained psychologists to lay personnel after brief training sessions. (Meichenbaum 1985; Driskell and Salas 2013)

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Stress inoculation training has been demonstrated to help reduce stress and improve performance in a number of professions, including police, military, athletes, teachers, and nurses. (Meichenbaum 1985) When lay people underwent stress inoculation training in addition to normal CPR training, they were more likely to use their skill is a test setting and performed more accurately. (Whitelock and Asken 2012) These studies are promising, and stress inoculation seems to generalize well, but if should be noted that there has not yet been any research demonstrating benefit of stress inoculation training in medicine.

A note about evidence: social science research often has weaker methodology than we are used to in medicine, but because stress exposure training started as a clinical intervention, the methods here are stronger. (Driskell and Salas 2013) One review, in which 85% of included studies were randomized trials, found that 67% of published trials reported statistically significant improvements in performance with stress exposure training. (Driskell and Salas 2013)

The goal of stress inoculation training is not to eliminate stress. No single stress management technique has been shown to be universally effective. The goal is to learn the nature of stress then develop and practice a variety of skills to draw on when necessary.  (Meichenbaum 1985)

For an eye-opening and insightful firsthand account of how stress exposure training is done in the military, read “Stress Inoculation Training” by Mike Lauria

stress inocculation training


“Mindfulness is the skill of being deliberately attentive to one’s experience as it unfolds – without superimposition of our usual commentary and conceptualizing.” (Ludwig 2008) Studies have indicated that mindfulness can improve our ability to control focus and attention. (Deuster and Schoomaker 2015) Mindfulness has also been shown to improve working memory, and in particular, it may counter the impairment of working memory caused by stress. (Deuster and Schoomaker 2015) Mindfulness is also an effective tool in emotional self-regulation, as one learns to observes their emotional experiences without immediately reacting to or trying to change them. (Deuster and Schoomaker 2015)

The majority of our thoughts and emotions occur without our being actively aware of them. We often react automatically, without being fully aware of the emotional, social, and cognitive factors impacting our current state. There are almost as many definitions of mindfulness as there are class , but for me the essence is simply promoting an active awareness of one’s body and thoughts. The only caveat is to approach that awareness non-judgmentally.

For example, through mindfulness, you might become aware of a tightness in your muscles that you recognize as indicating that you are becoming frustrated with a team member during resuscitation. Being non-judgemental means recognizing those sensations as normal responses to a normal human emotion that is neither good nor bad. The key to mindfulness in resuscitation is learning to recognize those sensations, acknowledge them, but then put them aside so you can focus on what is truly important to you: saving the patient. Putting these thoughts aside takes practice, but can also be helped by a number of the techniques discussed below, such as tactical breathing, self talk, and cognitive re-framing.

You can learn more about mindfulness meditation in Scott Weingart’s SMACC talk “Kettlebells for the Brain”

Although mindfulness is often spoken of as if it were a panacea of sorts, there is still a great deal we don’t know (like many of the topics discussed here). Is mindfulness equally effective for all people? Are there harms of mindfulness practice? How much training is required and what should that training look like?

Hope: If you are liking the class, then stay tuned, keep learning in the class, then you know.

Being mindful of attention

Concentration is not automatic. It takes a lot of energy to concentrate, and our ability to concentrate can become significantly impaired under stress. (Whitelock and Asken 2012; Grossman and Christensen 2004) Attention can be broad or narrow. In emergency resuscitation, we frequently require both kinds of attention. Broad awareness or situational awareness is essential for leading a resuscitation. However, when performing a specific skill like intubation we often require a much more narrow scope of focus. (Whitelock and Asken 2012)

We can probably improve our concentration skills through training. This is really the entire basis of mindfulness meditation strategies, but if meditation scares you, just focus on your concentration skills. Pick a small subject to focus on. It could be an external subject, like a laryngoscope blade, or it could be part of you, like your hand and the sensation of the laryngoscope as you hold it. Just focus on that subject. Take in all the details. Try to notice as many attribute as possible: the weight, the temperature, the size, the solidity. If you are focusing on your hand, pay attention to the feeling of the skin, the muscle tension, any pulsations you can feel. Practice maintaining this focus for as long as possible. If other thoughts come into your head, that is okay, because the key to improving focus is practicing bringing your attention back to the object after those distractions. As you improve, the exercise can be made more difficult by adding distractions, like music or TV in the background. You can also practice shifting your focus from narrow to broad and back again, by trying to focus only on the object to the exclusion of everything else for 30 seconds, and then shifting your attention broadly to everything in the room for 30 seconds, and then repeating. (Whitelock and Asken 2012) With time, this type of exercise should help you focus your attention where you need it in the resuscitation room, and to quickly switch back and forth from the broad situational awareness required to lead a resuscitation to the very narrow focus required to complete a procedure.

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Jason Brooks talking about focus:


Overlearning is continuing to practice a skill after one is already competent. (LeBlanc 2009; Driskell and Salas 2013) One of the major benefits of overlearning is that once a skill is overlearned, it can be automated and therefore requires less concentration and working memory, potentially improving performance under pressure. (Whitelock and Asken 2012; Driskell and Salas 2013) Overlearning can also simplify more complex tasks, and simple tasks are less likely to be impaired under stressful conditions. (LeBlanc 2009; Driskell and Salas 2013) Overlearning might also create “muscle memory”, such that extensively practiced motor skills can still be relied upon under extreme stress. This has been demonstrated in police officers handling firearms and using handcuffs in “code red” even when other motor skills have deteriorated. (Grossman and Christensen 2004) Presumably, medical skills like vascular access would similarly benefit from overlearning. Finally, overlearning can increase one’s sense of control when performing a task. (LeBlanc 2009)

We fall to the level of our training under stress

The major drawback of overlearning is that it may limit one’s flexibility when responding to complex and changing conditions; one’s response may be to stick too rigidly with the skill that has been overlearned. (LeBlanc 2009) There are many examples of people identically replicating training drills under extreme stress. My favorite is the story of a police officer who overlearned the technique of disarming a subject with a gun at close range. Every chance he got he would have his partner point a gun at him, snatch it away, and then hand it back to repeat the process. One day when responding to an armed robbery he came face to face with a suspect who had a gun pointed directly at the officer. The officer immediately snatched the gun away and successfully disarmed the suspect, but the next move he had overlearned through extensive practice wasn’t as smooth: he immediately handed the gun back to the suspect like he had so many times with his partner. Luckily, the suspect was so surprised that the officer managed to disarm him again, but the lesson is clear: you have to “practice like you play”, or make your practice sessions as close to real life as possible. (Grossman and Christensen 2004)

Overlearning should not be applied to all skills. You want to select skills that are likely to be universally adaptive as compared to those which may require more flexibility. You also want to avoid overlearning different possible responses to the same stimuli, as it could make deciding between the two option difficult under stress. (Driskell and Salas 2013) For example, I have applied the concept of overlearning to my surgical approach to a cricothyroidotomy, so it could be confusing to also attempt to overlearn a catheter based technique.

Stop succeed vs stop when cannot fail - overlearning to manage stress

Mental practice (aka performance enhancing imagery)

Performance can be improved through practice, training, and experience. Once a response has been learned, it no longer requires the same higher order cognition. This allows you to more rapidly choose among prelearned responses. (Leach 2004) Real life experience or simulated education are excellent ways to prepare for high stress scenarios, but are time consuming and often impractical. Mental practice is just like physical practice, except that it occurs entirely within your mind. It involves visualizing, in as much detail as possible, each step of the skill to be practiced.

Multiple studies, of mixed quality, seem to indicate a benefit of mental practice in sports and music. (Weinberg 2008; Driskell, Copper, and Moran 1994) In medicine, mental practice has been shown to enhance surgical and procedural skills. (Arora et al. 2011; Komesu et al. 2009; Sanders et al. 2004; Sanders et al. 2008) More recently, mental practice was also shown to improve performance in team based trauma resuscitation simulations. (Lorello et al. 2016)

However, not surprisingly, considering the many possible interpretations of mental practice and the breadth of medicine, there are also studies that show no benefit. (Hayter et al. 2013) Furthermore, mental practice is probably less effective than actual physical practice. (Driskell, Copper, and Moran 1994)

Effectiveness is probably increased when the practiced skill is visualized carefully, correctly, incorporating all the senses, and in real time. (Herzog and Deuster 2014) Much like physical practice, lazy or sloppy mental practice is unlikely to translate into improved performance. The accurate visualization required for mental rehearsal means that at least some real world experience of physical practice is required before mental practice can be employed. (Whitelock and Asken 2012)

In addition to physical skills, mental practice can probably also be used to help train your emotional responses. Have you ever had a bad encounter while working, got angry, and said something that you later regretted? Take a moment to recreate that moment in your head. In real time, recreate the conversation. Now feel the physical changes that accompany your anger. Are your muscles tight? Your heart racing? Try to experience everything about the scene, right down to the smells in the room. Now that you can recognize the anger developing, picture yourself responding as you wish you had acted rather than as you actually did. Envision yourself taking a few deep breaths. Try to see things from the other side. Is this person really a jerk, or are they just scared or tired or struggling with their divorce? Envision yourself pausing to breath and think before you respond. If you mentally rehearse both the sensations of anger and your planned response, you are much more likely to recognize when you are becoming angry, and respond in a way that that fits with your professional ideals.

Hope you have understood completely what we have been told in this class….If yes then also join our upcoming classes and share your feed.Thank you

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