Performance Under Pressure part 1

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

How well do you perform when the pressure is high? How well do you manage stress? This is one of my favorite emergency medicine topics. Emergency personnel pride themselves on thriving under pressure. Doctors like to think of themselves as perfect, maybe even god-like. Combine the two, and you can imagine the ego of the average emergency physician. But underneath all that bravado, we are all human. We all experience stress, and we all respond to stress in distinctly human ways.

I like talking about performance under pressure precisely because we don’t talk about it. Because if stress is mentioned in an emergency medicine context, it is to say that we should “just handle it and get on with our jobs”. Because we all experience stress – pretty extreme stress – and yet it wasn’t mentioned once in my medical school or residency training.

We send people out into the wild just expecting them to cope. For the most part, we do cope. Some people develop great coping strategies. Unfortunately, others use maladaptive strategies,  or don’t learn to cope at all, until it’s too late.

What follows are my relatively extensive notes on stress, how it affects us, and the various ways we might be able to effectively manage stress to ensure that we are performing at the extremely high level demanded of us.

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

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What is stress?

This is a surprisingly difficult question to answer. There are many competing definitions of stress in the literature without a clear winner. (Driskell and Salas 2013) However, although a precise definition might be helpful for research, for emergency medicine I think the definition is less important. Emergency clinicians know exactly what stress is, even if we can’t specifically define it.

There is a general sense that stress is always bad, but as we will discover as we work through the literature, it doesn’t have to be. The stress response is an important physiologic phenomenon. Emotions are rarely just good or bad. We often consider fear to be inherently negative, but we need fear to help us avoid potentially dangerous situations. Happiness is considered inherently positive, but if we were happy all the time, we would never accomplish anything new. Stress is similar. Without a stress response our responses to emergencies would be lackadaisical and ineffective. Emotions are neither inherently harmful nor beneficial. Emotions become harmful when they are the wrong intensity, for the wrong duration, occur with the wrong frequency, or are the wrong type for a particular situation. (Gross 2015)

There are two types of stressors we that will commonly be faced with. Primary stressors are those which arise from the demands on the task in front of us, such as the blood obscuring our view of the airway. Secondary stressors are aspects of the situation that are unrelated to the challenge itself, like being afraid of failure, wanting to perform well in front of others, or generally feeling ill prepared. Primary stressors can help you step up your arousal to meet the challenge in front of you. Secondary stressors are more likely to impair performance because they are unpredictable, harder to control, and unrelated to the task at hand. (Whitelock and Asken 2012)

Stress is a transactional state. It is neither something external to you, nor a purely internal response. It is the result of the interaction between the individual and their environment. (Meichenbaum 1985) This is an essential concept, because it is the transactional nature of stress that makes the various cognitive techniques discussed below effective.

When coping with stress, we can break our responses in to two broad categories. Problem focused coping aims to manage negative emotions by addressing the underlying problem. Emotion focused coping aims to manage emotions directly without addressing the underlying problem. (Driskell and Salas 2013; LeBlanc 2009) Problem based coping strategies are ideal in controllable situations, whereas emotional based strategies are useful when stressors are brief and uncontrollable. To perform optimally under pressure, you will ideally be able to draw on both problem focused and emotion focused coping techniques.

The threat challenge assessment

Before we get into the various physiologic and psychologic effects of stress, it is important to note that an individual’s response to stress is heavily influenced by the person’s assessment of the situation. (Kowalski-Trakofler et al 2003; Driskell and Salas 2013) First, we assess the demands of the situation: what is required of us to achieve a goal. Next, we assess the resources, personal and environmental, that we have to achieve that goal. When resources are sufficient to deal with the demand, we frame the situation as a challenge, and a positive psychologic state of “eustress” ensues that supports optimal performance. When demands outweigh resources, we see a threat, and a negative psychologic state of “distress” results than can impair performance. This response is subjective and primary based on the individual’s perception of the demands and resources. Any factor that increases perceived demands or decreases perceived resources increases the likelihood of a distress response. (Weisinger and Pawliw-Fry 2015; LeBlanc 2009)

Treat Challenge Assessment to stress

How does stress affect us?

Physiological changes

There are a number of different physical manifestations of acute stress. We have all experienced the sweaty palms, rapid heart rate, and GI upset that can accompany stressful scenarios like oral exams or job interviews. At higher stress levels, tunnel vision can occur, potentially leading to decreased situational awareness and missed information. (Whitelock and Asken 2012; Grossman and Christensen 2004) Auditory exclusion or “tunnel hearing” can impair communication. (Whitelock and Asken 2012; Grossman and Christensen 2004) Perceptions of time can either speed up or slow down. (Whitelock and Asken 2012) Peripheral vasoconstriction results in impaired fine motor control and tremors can develop as the result of high sympathomimetic tone. (Grossman and Christensen 2004)

Of course, acute stress reactions are complex and occur in a myriad of situations. In a survey of police officers who had been involved in gunfights, 85% reported diminished hearing or auditory exclusion, but 16% reported sounds being intensified. (It adds to more than 100% because some officers experienced both at different times during the encounter.) Likewise, although 65% of officers experience time as slowing down, 16% experienced it as sped up. (Christensen 1997) The variety of possible responses make it hard to predict the response that any one individual will have in a given stressful situation. Likewise, it is difficult to extrapolate studies of stress from other fields into the realm of medicine.

The physiologic response to stress seems to be, at least in part, modulated by the threat-challenge assessment. A challenge state is associated with improved cardiac efficiency, dilation of peripheral vasculature, and low cortisol levels. A threat assessment, on the other hand, is associated with peripheral vasoconstriction, diminished cardiac output, and elevated cortisol levels. (Jamieson, Mendes, and Nock 2013)

Psychological changes

The ways in which our thinking changes under stress are probably even more important in emergency medicine. There are four major steps at which stress can impair behaviour: it can impair perception of the problem, analysis of the problem, decision making, and motor action. (Whitelock and Asken 2012)

We all know about the “fight or flight response”, but there is actually a third common response to stress: freezing. (Whitelock and Asken 2012) Impaired concentration and slowed decision time are common under stress. (Whitelock and Asken 2012; LeBlanc 2009; Petrosoniak and Hicks 2013) Stress can also lead to more impulsive behaviours, resulting in “rescue fever”, where rescuers rush into unstable or unsafe scenarios. (Whitelock and Asken 2012)

Acute stress can result in a loss of situational awareness. (Petrosoniak and Hicks 2013; Driskell and Salas 2013) For this reason, among numerous others, stress has also been demonstrated to impair team performance. (Petrosoniak and Hicks 2013; LeBlanc 2009)

Selective attention is important mental process in the chaos of the resuscitation room. It is the process that allows us to focus on a single object, and to exclude others from our attention. Under pressure, attention is naturally focused on the locus of stress. Therefore, if the stress is intrinsic to the task being performed, attention will be focused on the problem at hand, and performance shouldn’t be adversely affected. However, if the stressors are external, such as loud noises, a screaming family, or disruptive team members, attention will be drawn away from the task at hand, and performance is likely to suffer. (LeBlanc 2009) Similarly, performance on divided attention tasks, or those that require integration of information from several sources (such as complicated medical resuscitation) generally suffers under pressure. (LeBlanc 2009)

Stress has a variety of impacts on memory. (Petrosoniak and Hicks 2013; Grossman and Christensen 2004) Working memory seems to be impaired in the context of a threat assessment, whereas a challenge assessment results in no impairment. (LeBlanc 2009) With regards to forming new memories, stress can either impair or enhance the process. When the stressor is directly related to the memory, memory improves. However, if the stressor is something peripheral to the thing to be remembered, memory seems to be impaired. (LeBlanc 2009) In terms of memory retrieval, stress is an impairment, but that impairment seems to be limited to individuals who assess the situation as a threat as opposed to a challenge. (LeBlanc 2009) Furthermore, stress has less of an impact on memory retrieval in individuals with a great deal of experience. (Driskell and Salas 2013)

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The impacts of stress on decision making are somewhat complex, and I will explore them in a little more detail below. Generally, stress results in a greater reliance on heuristics and a reduced ability to analyze complex situations, with more classic errors in reasoning. (Petrosoniak and Hicks 2013; LeBlanc 2009; Driskell and Salas 2013) Decisions made under stress tend to favour lower risk or “more certain” options. (Driskell and Salas 2013) Stress can also result in tactical fixation: the failure to change strategy when needed. (Whitelock and Asken 2012; Driskell and Salas 2013)

One might ask whether these stress responses are only observed in the psychology lab, or whether they have impact in the real world. (On the other hand, if you have experienced extreme stress, that might seem like a silly question.) Grossman’s “On Combat” is full of real stories from soldiers and police officers that illustrate the occurrence of all of the above physiologic and psychological changes in real people under extreme stress. (Grossman and Christensen 2004) It is even commonly reported that, under extreme stress, people are physically incapable of the relatively simple task of dialing “911”. (Grossman and Christensen 2004) Although stress responses are variable and complex, I don’t think that there is any doubt that they play an important role in real world performance under pressure.

Stress in medicine

I am not aware of any study categorizing the impacts of stress during live medical resuscitation. However, speaking with colleagues, it is clear that many of us have experienced phenomena similar to those reported by soldiers and police officers. Personally, I have experienced a degree of tunnel vision while performing time-sensitive procedures on dying patients. I have experienced auditory exclusion: not hearing the handover from paramedics because I was too focused on the scene in front of me. I have had trouble remembering the details of a horrible pediatric resuscitation as I tried to chart later. The study might not exist, but I think it’s clear that these stress responses are a daily occurrence in resuscitation rooms.

The Siddle and Grossman classification

The classification of physiologic responses to stress based on heart rate by Siddle and Grossman is frequently reproduced. (Grossman and Christensen 2004) The classification of various responses based on a specific heart rate is likely inaccurate, a point that Grossman specifically emphasizes. An individual’s heart rate and response to stress can vary significantly based training, physical fitness, and a variety of other factors. (Grossman and Christensen 2004) However, I think the schema is still helpful as an overview of the various physiologic responses to stress:

Grossman Heart Rate Stress classification

The key here is not the specifics about heart rate, but that our physiologic responses to stress follow a fairly consistent and predictable pattern. As stress increases, you first enter a phase of increased alertness and concentration. As stress mounts, fine motor skills, complex motor skills and reaction time improve, plateau, and then deteriorate. Fine motor skills will deteriorate before complex motor skills, which will, in turn, deteriorate before perceptual changes like tunnel vision, decreased hearing, and distorted time perception begin. (Grossman and Christensen 2004) We all experience some version of these physiologic changes. Have you ever had trouble writing legible notes after a particularly hectic resuscitation? That is probably the result of the peripheral vasoconstriction and catecholamine release that consistently degrades fine motor skill under pressure.

The ideal zone of performance will be different for different activities. Grossman is discussing military and police performance, where performance requires more gross motor skills, and suggests “condition red” is the optimal zone of performance. In medicine, with a higher reliance on fine motor skills, we might be be better in condition yellow. Grossman also emphasizes that, with training, you can expand the zones, meaning you should be able to tolerate higher levels of stress before performance diminishes. (Grossman and Christensen 2004)

For a little more on Grossman’s book, you can turn to EMCrit episode 118: EMCrit book club – On Combat by David Grossman

Performance under pressure (How to manage stress)

The research on how we perform under pressure is somewhat mixed. Some studies indicate impaired performance under pressure. (LeBlanc et al. 2005; Cumming and Harris 2001) Other have demonstrated improved performance. (LeBlanc et al. 2005; LeBlanc et al. 2008)

The Yerkes Dodson law suggests that for any activity there is an optimal level of arousal for peak performance. The common illustration is a simple curve that demonstrates that performance suffers both in states of high and low arousal. However, the original Yerkes Dodson data divided tasks into two groups, and for simple tasks like focused attention, there did not seem to be a significant drop off of performance at higher levels of arousal. (Diamond et al. 2007) The goal of training is to change the shape of this curve, such that optimal performance can be achieved over a wider range of conditions.

Yerkes Dodson cure - stress levels for optimal performance

The exact mechanisms through which stressors result in changes in performance are debated. Clearly, there are some physiologic and hormonal changes at play. Stressors may also act as distractions that limit one’s available attention. (J. E. Driskell, Johnston, and Salas 2001) Another factor that determines one’s ability to deal with stress is prior experience with stress (this is one of the key tenets of stress inoculation therapy, discussed below). (Meicheribaum and Novaco 1985)

You can read more about this topic in Mike Lauria’s post “The Tao of Resuscitation Performance”

Thinking under pressure

Daniel Kahneman has popularized the concept of system 1 and system 2 thinking. System 1 represents intuitive, unconscious reasoning that relies on heuristics or mental shortcuts. It is quick and requires minimal effort. Consequently, it is the process used most frequently. However, because of its reliance on heuristics, system 1 is prone to bias and cognitive errors. System 2, on the other hand, represents conscious, analytic thought. It is slow, deliberative, and requires significant effort. It is generally thought to be less prone to errors. (Kahneman 2011)

In high pressure, critical situations, system 2 is likely to fail. System 2 is slow – slow to accept changing reality and slow to act. (Grossman and Christensen 2004) We know that we rely more heavily on heuristics under pressure. (LeBlanc 2009) This is often thought of as weakness, but it’s not clear that system 1 thinking is necessarily a weakness when employed by experts, especially in time critical scenarios. Intuition is one of our most powerful tools in a crisis. (LeBlanc 2009; Grossman and Christensen 2004)

Decision making definitely changes under pressure, but it is less clear if those changes degrade performance. The decisions made are generally simpler, but are often rational and make important use of experience. (Driskell and Salas 2013) In a classic laboratory experiment, subjects were required to run a computer simulated forest fire management task. Half of the subjects were placed under an external stress (loud noise). The problem solving strategies differed significantly between the groups, with the unstressed group relying on in-depth analytical analysis and the stressed group focusing only on the general outline of the problem. However, despite the differences in approach and different types of errors made, both groups performed the task equally well. (Dörner and Pfeifer 1993)

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Under time pressure, people tend to adopt simpler forms of information processing, in which alternatives are not fully formed, and certain important cues or patterns are used to rapidly make a decision. In other words, people narrow their field of attention under stress. (Kowalski-Trakofler et al 2003) If this narrowing of attention results in important information being missed, performance would suffer. However, if the narrowing of attention allows the individual to ignore nonessential information and focus on only the most important cues, this could be an effective and efficient cognitive strategy. (Kowalski-Trakofler et al 2003) Furthermore, even if the decision making is technically inferior, it makes little sense to use a time consuming analytical strategy when faced with severe time pressure. (Driskell and Salas 2013)

A number of alternative decision strategies have been described in stressful scenarios. A lexicographic strategy simply looks at a single important dimension of the choice and picks the option with the best rating in that dimension. An elimination by aspects strategy involves evaluating all options on the most important dimension and rejecting options that fail to meet the desired criterion. The remaining options are then evaluated on the next most important dimension, until only one option remains. (Driskell and Salas 2013) Although these strategies are not the ideal logical strategy, they are quick, efficient, and may be good enough, when employed by experts, for the type of rapid decisions that are necessary in emergencies. Interestingly, the closer together two options are, the less important the decision making becomes. In other words, when there is a clear winner, the choice is often obvious, but when two choices are very similar, the outcome may not be significantly affected, and therefore the decision becomes less important. The ambiguity of the data in emergent scenarios may outweigh the advantages of any one option.  (Driskell and Salas 2013)

Recognizing that the decision making done in complex, real world scenarios is different from that performed in psychology laboratories, naturalistic decision making is a theory based on empiric observation of real world experts decisions. (Driskell and Salas 2013) Recognition-primed decision making is one of the models that developed out of this research. Recognition-primed involves rapid pattern matching, followed by a brief mental simulation to determine if the initial option is a reasonable solution in this scenario. (Klein 2008) You can read more about naturalistic decision making on the International Clinician Educators blog.

There is a very large body of research that addresses decision making under stress, but the vast majority of these studies were performed in highly controlled psychology laboratories. How applicable these are to real world settings in general, and medical resuscitation in particular, is an open question. (Kowalski-Trakofler et al 2003) The case studies that examine decision making in real world crises generally conclude that decision making deteriorates under stress, but these conclusions must be tempered by the fact that information is often incomplete and even incorrect in times of crisis, which would make perfect decision making essentially impossible. (Driskell and Salas 2013)

All the research on decision making under stress is subject to significant assumptions. Either you examine the decision making itself and make assumptions about the best kind of decision making, or you examine outcomes. The problem with examining the decision making strategy itself is that there is considerable debate about the ideal decisions strategies. It isn’t clear that system 2 thinking is really better than system 1, especially in emergencies. The problem with examining outcomes is that decisions are not perfectly correlated with outcomes. Good decisions, for a variety of reasons, can still result in bad outcomes and vice versa (resulting in hindsight bias).

For now, I think the best we can do is acknowledge that decision making patterns change under stress. It is probably not appropriate to try to force slow, methodological type 2 thinking on fast paced medical resuscitations, but recognizing our reliance on heuristics, we might want to build in checklists or cognitive stop points that allow us to think about our thinking, when there is time.

For more about decision making in the resuscitation room, make sure to review Scott Weingart’s talk on OODA loops.

The optimal zone or “flow”

Watch any sport long enough and you will inevitably hear about an athlete who is “in the zone”. If you have worked in emergency medicine long enough, I am sure you have a sense of what this means. You are running a resuscitation and everything just clicks. Your thinking is perfectly clear, time appears to slow down, everything is working, and the job just seems fun.

For any activity, there is a balance between your skill, resources and the demands being placed on you. If the demands outstrip resources, we see anxiety and poor performance. When skill or confidence significantly outstrip demands, we see boredom that could also degrade performance. Somewhere in between, there is a zone that leads to optimal performance. The level of difficulty is high enough that it demands your entire attention, but not so high that is begins to impair your cognitive abilities. Performance in this Goldilocks zone is often referred to as being in a “flow state”. (Whitelock and Asken 2012; Herzog and Deuster 2014)

Flow state matching challenge to skill

In emergency medicine, we generally aren’t worried about low challenge states (although it is important to have cognitive tools to harness your quasi-ADHD as you drift into the boredom area of this graph). In general, when we are talking about performance, we are talking about extremely challenging situations. Looking at the graph gives us some hints as to how to handle this. We can and should focus on ensuring we are as skilled as possible. The degree of challenge seems like it would be out of our control, but in fact, it is our subjective interpretation of the challenge that really matters. We can learn cognitive tools that help regulate our sense of challenge, and therefore bring ourselves back into “the zone”. (Herzog and Deuster 2014)

In medicine

Impaired performance in stressful, high-acuity scenarios has been reported in medical students, paramedics, and staff surgeons. (LeBlanc et al. 2005; Leblanc et al. 2012; Piquette et al. 2014; Harvey et al. 2011; Arora et al. 2010; Krage et al. 2014) For example, in one study, emergency medicine and surgery residents were evaluated in both a high stress and a low stress trauma simulation. In the high stress scenario the patient was sicker, was a young pregnant female (for emotional stress), involved a compatriot paramedic who questioned the residents’ decisions, and had higher ambient noise levels. Cortisol levels were measured and were higher in the high stress scenario, indicating physiologic differences. Scores of resident performance, using a previously validated score, were lower in the high stress scenario. This is a believable study that demonstrates impaired performance in a stressful scenario, but there are significant limitations: it takes place in a simulated environment and studies learners rather than experts. (Harvey et al. 2011) In other studies, performance was not seen to deteriorate despite higher reported stress levels. (LeBlanc and Bandiera 2007; Bjørshol et al. 2011) With regards to how stress impacts the performance of expert clinicians in the resuscitation room, the evidence simply doesn’t provide us with a good answer.

That’s all in this class, we will discuss about it in the next class part 2

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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