Acute stress management training for elite performance under pressure

Abstract

Effective approaches to acute stress management in healthcare are more urgently needed than ever, given the increasing pressures teams face, generating chronic stress, which can decrease overall baseline resilience. While these chronic stressors range from waning resources to growing medical deserts, acute sources of stress emerge from deteriorating patients, leadership or personnel crises, or rapidly developing medical innovations with increasing clinical time demands given provider coverage gaps. Traditional wellness or stress-management curricula at the undergraduate, graduate, and continuing education levels focus heavily on individual provider betterment and resilience to deal with everyday chronic stressors. However, they lack a focus on teaching specific skills to manage these acutely stressful situations, which can occur regardless of specialty. Just as elite athletes must prepare for the most stressful aspects of their careers, we should also be training with techniques to perform at our best in these moments, whether they involve a deteriorating patient, ongoing team conflict, or sudden systemwide challenges. In this article we review the case for acute stress training at all levels of education within healthcare and propose tactics from multiple high-stress disciplines, including those outside of healthcare, to fortify clinician performance no matter the circumstances.

Modern healthcare teams deliver care in an environment often laden with nonmedical challenges. These include regional and national workforce shortages, increased administrative burden, and an accelerating rate of change in both scientific and political healthcare recommendations. While these factors can contribute to chronic stress and the much-covered concept of “burnout,” clinicians are also often faced with acutely stressful “bedside” situations which can compound these challenges. Acute stress can be induced by high-acuity medical situations and sicker patients,^1,2 but can be experienced by any clinician facing difficult decision-making or skill execution. This is particularly true in clinically or structurally time-sensitive settings. Acute stress is likely exacerbated by chronic stressors, and vice versa.

The evidence of acute stress is found throughout medicine. In the midst of the first wave of the COVID-19 pandemic, as many as 64.9% of frontline healthcare workers reported symptoms of acute stress.³ While that level of exposure to acute stress has lowered in the years since the pandemic, as many as 45.2% of physicians report suffering from symptoms of burnout, which are linked to long-term exposure to acute stress.⁴ Therefore, recognizing, mitigating, and managing acute stress should be a core competency of clinical teams.

Acute stress can spike in seconds to minutes. Above a certain threshold, acute stress elicits a catecholamine burst, disrupting executive functioning via dysregulation of prefrontal cortex inputs, degrading working memory and attentional control.^5–7 This produces a shift from a reflective to a reflexive state of thinking, which takes the prefrontal cortex offline, bypassing control from these higher cortical centers and amplifying inputs from the insula and amygdala.^5–7 This strong neurophysiological effect produces outcome differences; at the point of care, this can manifest as poorer operative performance during times of unexpected acute blood loss,⁸ lower-quality cardiopulmonary resuscitation,⁹ and compromised leadership and decision-making.¹⁰ Acute stress and the emotions it produces are also contagious.¹¹

While stress management and burnout continue to be a focus of many undergraduate and graduate medical education initiatives, we submit that these typically target sources of chronic stress and thus they propose more long-term stress reduction strategies, which neglect specific in-the-moment techniques for acute stress management. Evidence-based techniques for mitigating acute stress are deliberately used in other fields, such as the military, elite athletics, and public safety,¹² and import well into healthcare. While recent publications highlight the need for consistent and intentional training during residency,^13,14 we take this a step further and propose a continuum of training throughout the lifetime of a clinician, from undergraduate, through graduate, and into continuing education curricula.

BRIEF OVERVIEW OF STRESS IMPACTING PERFORMANCE

In increasingly stressful workplace environments, clinicians can experience immediate and often negative effects. While research is conflicted, it is generally thought that uncontrolled stress can shift from being a motivator to a strong cognitive impediment at both the personal and team levels.^5–7,15 Exactly where this tipping point occurs differs between individuals, and even an individual’s threshold can change at different times.¹⁵ Because acute stress disrupts inputs from the prefrontal cortex to myriad areas of the brain, this compromises a clinician’s ability to perform higher-order reasoning and complex decision-making. When such “in-the-moment” acute stress propagates unchecked, it can have longer-term impacts—functionally, on working memory,¹⁶ and structurally, on causing dendritic atrophy, leading to lower synaptic plasticity.¹⁷ Both functional and structural changes lead to cognitive impairment and reduce capacity for current and future decision-making.

Emotions elicited by acute stress can spread throughout a team, compromising teamwork and even leadership. Leaders can be highly susceptible to these emotions when not trained in stress mitigation methods. When a leader behaves irritably, this can worsen team members’ performance¹⁸ and possibly their decision-making, as negative emotions elicit cognitive biases (or shortcuts), which are more vulnerable to errors.¹⁹ When a leader is in a more positive emotional state, achieved through techniques described below, teams can function better overall.²⁰ Additionally, recent literature calls for a standardized leadership skill set, with central tenets emphasizing care for others, forward progress, and intentionality in cultivating interpersonal relationships among team members and between team members and the leader, which is hypothesized to improve overall team performance and well-being.²¹ Thus, all team members are impacted by acute stress felt by even one person, reinforcing the important skill of managing acute stress in medical environments.

Recognizing stress in oneself and within the team can be a challenge, though most people can differentiate the feelings associated with stress from a calm, relaxed, or more neutral state of being. However, it is less clear exactly when acute stress transitions from performance-enhancing to hampering decision-making capability. Severe acute stress reduces capacity for introspection or metacognition through effects on prefrontal cortex inputs, especially when individuals have not had stress recognition training.²² Some external indicators of stress, especially at the team level, may merely be felt as rising tensions coupled with worsened task coordination and communication breakdowns.²³

In sum, although acute stress is an inevitable byproduct of high-acuity scenarios, its impact on performance is not fixed. Unchecked or uncontrolled stress can disrupt executive control, reduce cognitive and procedural performance, and spread through teams. This can lead to patient harm and long-term damage to clinician performance and confidence.

MANAGING ACUTE STRESS: LESSONS FROM OTHER FIELDS

Many high-stakes fields, such as the military, aviation, public safety, and elite sports, have invested in recognizing and managing the potential for critical moments to generate uncontrolled stress. While headway has been made in raising awareness and concern regarding acute stress in healthcare, the few techniques reported to teach acute stress management are incompletely applied.^9,12–14 Currently, mechanisms for stress management and resilience in medical environments exist primarily at the meso (organizational/hospital) level, leaving gaps in methods of individual/team stress management and resilience. Healthcare has adopted successful techniques in the past, checklists from aviation being a notable example,²⁴ and should be willing to liberally borrow more such methods. Some methods are highlighted in Table 1 and described below.

Table 1.

Stress management tactics

Tactic	Strategy	Field	Outcomes
Distraction-based interventions	Utilization of an additional, unrelated stimulus to distract from the stressful stimulus in practice	Sports	Improves focus in actual game play, as all attention is now focused on the stressful stimulus; also enables individual to become accustomed to performing under stress
Acclimatization	Practice under the same stresses one will encounter in actual environment	General	Allows for individual to become accustomed and thus less susceptible to acute stressors
Visualization	“Mental rehearsal” or practice of working way through the steps required to combat an acutely stressful situation	General	Helps to reduce cognitive load during implementation of planned steps during real-life situation
Crew resource management	Implementation and practice of a standardized set of procedures that improves team communication and efficiency	Aviation	Maintains and reinforces team dynamics and function under times of high stress and duress
Stress inoculation	Education of individuals about stress subject, with gradual increase of exposure to source of stress	Military	Blunts cognitive and physiological response to source of stress
Automatic regulation training	Training centered around managing emotional response to stress by emphasizing communication and deescalation	Police	Preserves accuracy and attentional control in shoot/no-shoot tasks
Virtual reality	Practice beyond simple visualization, allowing the individual to rehearse the steps required to deal with acutely stressful situations, reducing stress in real time	General	Offers extra practice (beyond simple mental rehearsal but not yet under the stress of real-world consequences), which reduces the stress response in the individual
Nonconscious goal pursuit	Continuous implementation of set practices in response to stressors and when focused on achieving a specific goal	General	Allows for individuals to develop automatic, nonconscious responses when confronted with acute stressors, reducing cognitive load and enabling the individual to operate on autopilot
Cognitive reappraisal	Similar to visualization, with reframing of a stressful situation in order to reduce focus on its negative aspects	General (military, police)	Improves subjective view of stressful situations in real time as well as response and recovery time to acute stressor
Relaxation techniques	Practices that reduce physical responses to acute stressors	General	Allows for individual to react to acute stressor in a more level-headed manner

Stress inoculation training, a cognitive behavioral technique, is one such method used routinely in military settings. This involves educating members on stress and then gradually exposing them to higher amounts of stress over time while teaching adaptive techniques to manage it.²⁵ Underpinning this technique is the idea that continued exposure to stress, including uncontrolled stress, eventually blunts the physiological responses and cognitive assessments of stress. This has recently been explored using virtual reality (VR) to expose novices (i.e., medical students) to the stress of managing malignant hyperthermia, with some success at generating stress through VR as well as reduced physiological markers of stress seen after repeated exposures.²⁶ VR may be uniquely suited to reproduce stressful environments tailored to individuals’ needs.²⁴ With other groups, such as astronauts²⁷ and athletes,²⁵ similar gains from stress inoculation are seen with blunted stress responses and improved performance.

Athletes can freeze, or choke, under the stress of various distractions they encounter midgame. Similar to stress inoculation, studies have shown that distraction-based training, such as a team member jumping up and down behind a goal post while an individual prepares to shoot a basketball, can actually improve the performance of these individuals in the game.²⁸ Law enforcement officers consistently make high-impact decisions under duress, such as in “shoot/no-shoot” situations. When police officers are subjected to acute stress in these situations, studies have shown that their perceived threat is higher, leading to an increased likelihood that the gun will be fired. In studies where law enforcement training involved being subjected to similar stressors that police officers are likely to encounter in the field, there was demonstrated improvement in accuracy even months after the original test. In comparison, when trainees were not subjected to acute stress, they did not perform as well in real-world situations.²⁹

Stress inoculation itself may deliver benefits but is made more durable by pairing with adaptive techniques, including activating beneficial mindsets,³⁰ cognitive reappraisal,³¹ and relaxation techniques that uncouple amygdala and insular inputs.³² By habitually applying these tools, their use becomes unconscious, such that they are elicited automatically and allow the individual to maintain a fast response time under strenuous circumstances.³³ Education in these techniques alone is not enough; regular intervals for practice reinforce these critical skills.

Mindsets were popularized by Carol Dweck³⁴ from her early work in children where those who had adopted a stance of “skills can be grown” persisted longer and adapted more to stress than those who had a “skills are innate” approach. Thus, mindsets can be described as a set of beliefs about viewing the world a certain way, under differing circumstances. When Navy SEALs undergoing extreme stress training were assessed for mindsets, persistence, and performance through obstacle courses, those with a “stress-as-enhancing” mindset persisted through extreme conditions more consistently, with better performance, and with fewer negative reviews from instructors than those without.³⁰

Cognitive reappraisal, or reframing, is an adjacent concept whereby individuals actively strive to “see” a situation through another lens,³⁵ often highlighting beneficial or neutral components to reduce a situation’s emotional load. While it is effortful at first, eventually this reappraisal process becomes unconscious, automatically happening over time.^31,35 Military and aviation communities have developed and enacted programs showing improved subjective appraisal of stressful situations as well as faster physiologic recovery and more resilient performance under pressure.³⁶ When one person reappraises during stress, this approach is also contagious and reduces physiological stress in others.³⁷

Relaxation techniques, such as deep breathing to activate the parasympathetic nervous system,³² are helpful in reducing subjective and physiological indicators of stress.³⁸ These may require training to adopt triggers that initiate the techniques, as they may not necessarily be intuitive if not reliably practiced. Rituals or routines can also be relaxing through automating behaviors, decreasing cognitive load.³⁹ In this way, mental rehearsal or visualization may be helpful for training to automate steps. Mental rehearsal or visualization is the act of cognitively imagining progressing through steps of a task and has been shown in healthcare to have modest benefits for individual performance.^40,41

Decision-making clinicians must also be “performers,” as there is usually an audience present, ranging from other medical professionals to patients to families. This in itself can prove to be an additional unique stressor that can impact the overall performance of clinicians. Performing artists also experience this stress in a way commonly known as “stage fright.” Just as medical technologies outpace clinicians’ adoption rates and how quickly clinicians can adapt to them, performing artists face an increasing demand as their skillsets have grown in scope and they must master them to be successful.⁴² Studies have shown that psychological training methods, such as goal setting, establishment of routines, self-talk, and resilience training, can improve the effect of acute stress in performing artists. Additionally, mental rehearsal has shown significant promise for improved stress management.⁴²

Finally, with the first studies regarding the effect of acute stress on cognition stemming from observations in aviation,⁵ there are many lessons to learn from the field of flight. One method of acute stress management adapted from aviation is crisis resource management (CRM) training. This method centers around fundamental team-based skills, such as closed-loop communication, leadership, and delegation of tasks, that often fall to the wayside during training. Specifically, current CRM training includes following a series of specific steps even in the face of acute stress, where scripted language and “naming” a situation while delegating (“claiming” roles) and focusing on interventions (“aiming” the team) can help to rapidly organize a team.^43,44 Additionally, CRM training emphasizes the role and attitude of the leader on the team at large; leaders are encouraged to be receptive to input without sacrificing their ultimate decision-making capacity.^45,46

IMAGINING a NEW PATH FORWARD FOR ACUTE STRESS MANAGEMENT TRAINING

Based on the above strategies, we propose a concerted effort to educate, train, and refresh these skills and concepts to normalize adapting to the effects of acute stress (Table 2):

Table 2.

Proposed practices based on clinician level

Clinician level	Suggested practices	Anticipated effects of practices
Undergraduate	Introduction to biological responses to stress and how to handle these responses	Allows for early exposure to stress management and destigmatization of handling these stressors. Equips individuals with the skills required to deal with acute stressors before being placed into an environment with real-world consequences
Graduate	Introduction to and practice with stress inoculation Debrief of the stress itself in addition to debriefing of the clinical situation	Allows individuals to continue practicing prelearned stress management skills in increasingly stressful environments Involves recognition of stress from the leader, which enhances the effect of the stimulation and provides space for individuals to process and practice the stress itself without stigma
Practicing clinician	Continued access to professional resources that address acute stress management	Enables continued learning and reinforcement of stress management lessons Prevents learned tactics from falling to wayside

• At the undergraduate healthcare training level, students should be introduced to the biology of stress and the basics of self-regulation.^{5–13,15–17,22,23,31–35} Early exposure helps normalize conversations around stress, reducing stigma and equipping learners with micro-skills before they ever step into a stressful clinical scenario. Timing these interventions here also provides ample opportunity for practice throughout the continuum of training.

• Training during graduate levels should maintain these skills but add a focus on stress inoculation. High-fidelity simulation is useful to accurately replicate stressors,²⁹ but if time and expense are prohibitive, VR could be a useful proxy for simulation,^25–27 in addition to deliberately mentally rehearsing stressful situations.⁴⁰ When high-fidelity simulation is utilized, it is important to explicitly discuss stress response, rather than limiting debrief focus to clinical aspects of the case. Without this recognition from the simulation leader, the trainee may not benefit from the inoculating effect of the stress.

• Practicing clinicians through continuing education should be provided with easy-to-access resources at the professional society level for education and training. These resources would review and reinforce lessons regarding stress management offered in training, while further emphasizing the importance of stress mitigation at the team leader level and focusing on team-level impacts.^23,37,41 External motivators such as granting continuing education credits may be helpful to overcome complacency.

Early implementation of exposure to stress management is critical to combat acute stress in the clinical setting. At the undergraduate level, it is important to destigmatize mental health and the reality of acute stress in the workplace so that individuals may use stress relief tactics and ask for other resources when they start practicing independently.^47–49 At the graduate level and during the orientation period for hospitals, stress inoculation training bootcamps should be a required part of the curriculum. As a part of these stimulations, individuals will be able to implement prior learned practices of stress management when confronted with acute stressors without the additional stress of clinical consequences. Other studies have suggested that following participation in a stress management training intervention program, rates of anxiety and depression in nurses decreased.⁵⁰ In bundling this practice into the orientation period, acute stress management becomes hospital standard, which is critical to clinician health, performance, and improved patient care.⁵¹ For faculty, acute stress management skills should be assessed upon entry into a hospital system and then reflected upon at a later date.

For individuals, incorporating improved acute stress management has the potential to improve clinical well-being, improve performance under pressure, and contribute to patient safety.^{5–13,15–17,22,23,31–35} At the team level, practicing these strategies may foster coordination, accuracy, and error recognition.^{19,23,37,41,43} At the system level, stress management could lead to reduced errors and near misses, contribute to quality, improve staff retention, and improve adaptability in systemwide crises.⁵² Ultimately, patients benefit from a care team that can think clearly, communicate effectively, and recover swiftly even under duress.^{23,37,41,43,52}

CONCLUSION

Historically, healthcare and other high-stress fields implicitly taught that managing acute stress was either an innate skill or something best learned along the way. Some clinicians presumably do well under this model, though clearly not all benefit. Clinicians should strive for better skills to keep acute stress in the performance-enhancing zone through intentional training and deliberate practice and should borrow generously from other deeply knowledgeable professions. Ultimately, the lessons learned from these other fields paint a broader picture for creating better providers: teaching self-regulation early, practicing under realistic stress, and reinforcing through effective leadership behaviors and simulation. By embracing this framework, healthcare can prepare clinicians not just to survive acute stress, but to perform at their best when patients need them most.

Disclosure statement/Funding

The authors report no funding or conflicts of interest. This work is a product of the authors’ opinions and does not reflect official positions from their respective institutions.