Does stress training generalize to novel settings?

Some pressures are more equal than others: Effects of isolated pressure on performance

It is commonly assumed that performance is impaired by pressure and that different types of individual situational factors can produce equivalent pressure. Our aim was to explore the psychophysiological effects of pressure to test this assumption. Eighty-one novices completed a golf putting task under control and eight individual pressure conditions: time, difficulty, video, team, goal, fame, shame, and distraction. Performance was measured by the number of holed putts and ball-hole distance. Psychological, physiological and kinematic measures were collected. Performance was impaired by time and difficulty conditions but improved by team, goal and shame conditions compared to control. Perceived pressure and effort were higher than control in all conditions except distraction. Conscious processing was greater than control in all conditions except distraction and time constraint. Heart rate was faster with time, team, fame and shame. Heart rate variability and muscle activity were largely unaffected. Putter kinematics provided evidence of swing profiles slowing and/or becoming constrained in conditions where conscious processing increased, while the swing became faster in the time-pressure condition where conscious processing was decreased. Taken together, these results reveal heterogenous effects of pressure on performance, with performance impaired, unaffected, and improved by individual pressure situations. Similarly, heterogeneity characterized the effects of pressure on psychological, physiological and kinematic responses associated with task performance. In sum, the evidence challenges the standard tacit assumptions about the pressure-performance relationship in sport.

Decision Making Within and Outside Standard Operating Procedures: Paradoxical Use of Operational Discretion in Firefighters

OBJECTIVE

To understand how firefighters' use of rules (i.e., standard operating procedures [SOPs]) and deliberative decision making (i.e., operational discretion [OD]) interacts with acute stress.

BACKGROUND

Current operational guidance for UK firefighters combines the provision of SOPs, for routine incidents, with the use of OD, under prescribed conditions (e.g., when there is a risk to human life). However, our understanding of the use of SOPs and OD is limited.

METHODS

Incident commanders (ICs; n = 43) responded to simulated emergency incidents, which either licensed the use of OD or required use of a SOP. Video footage of IC behavior was used to code their response as involving a SOP or OD, while levels of acute stress were assessed using a blood-based measure and self-report.

RESULTS

ICs were less likely to use OD selectively in the simulated emergency incident that licensed its use than in the one for which use of an SOP was appropriate; IC command level did not affect this pattern of results; and the incident that licensed OD resulted in more acute stress than the incident that required use of a SOP.

CONCLUSION

SOPs and OD were not used in the manner prescribed by current operational guidance in simulated emergency incidents.

APPLICATION

These results suggest that firefighter training in SOPs and OD should be augmented alongside personal resilience training, given the impact of stress on health and wellbeing, but also to improve the deployment of SOPs and OD under stress.

A Lexical Approach to Assessing Stress: Development and Proof-of-Concept

OBJECTIVE

We describe a methodology that provides a nonobtrusive means of detecting stress and related deficits through the assessment of spontaneous verbal output in ongoing communications.

BACKGROUND

In high-demand environments, operational personnel are exposed to an array of environmental, task, and interpersonal stressors that can negatively impact performance as well as jeopardize safety and well-being. In these settings, the requirement exists to assess cognitive and emotional state "at a distance" and without interfering with ongoing performance.

METHOD

We describe a lexical approach to assessing stress effects from ongoing or spontaneous verbal output. This approach is examined in a spaceflight analog setting.

RESULTS

We assess stress effects in terms of five core dimensions and develop lexical indicators of these core stress dimensions and relevant sub-facets. We establish the proof-of-concept of this approach by presenting representative data from a spaceflight analog.

CONCLUSION

This approach provides an unobtrusive means to evaluate ongoing task communications at the individual and team level in order to assess cognitive/emotional states such as workload, negative affect, attentional focus, anxiety, and team orientation.

APPLICATION

There are many high-demand settings in which it is valuable to monitor the potential negative effects of stress on operational personnel. These environments include spaceflight, the military, aviation, law enforcement, and medicine.

The Effects of Stress on Tourniquet Application and CPR Performance in Layperson and Professional Civilian Populations

OBJECTIVE

The purpose of this study was to compare laypeople's and professional first responders' ability to perform tourniquet application and cardiopulmonary resuscitation (CPR) during calm and stressful circumstances.

BACKGROUND

Life-threatening bleeding is a major cause of death that could be prevented by fast and appropriate first aid interventions. Therefore, laypeople are now being trained in bleeding control skills, transforming them from bystanders to immediate responders. However, critics have questioned whether laypeople are able to perform during more stressful conditions.

METHOD

Twenty-four laypersons and 31 professional first responders were tested in two conditions: a calm classroom scenario and a stressful scenario consisting of paintball fire and physical exertion. Stress and workload were assessed along with task performance.

RESULTS

The experimental manipulation was successful in terms of eliciting stress reactions. Tourniquet application performance did not decline in the stressful condition, but some aspects of CPR performance did for both groups. First responders experienced higher task engagement and lower distress, worry and workload than the laypeople in both the calm and stressful conditions.

CONCLUSION

Stress did not affect first responders and laypeople differently in terms of performance effects. Stress should therefore not be considered a major obstacle for teaching bleeding control skills to laypeople.

APPLICATION

Tourniquet application can be taught to laypeople in a short amount of time, and they can perform this skill during stress in controlled settings. Concerns about laypeople's ability to perform under stress should not exclude bleeding control skills from first aid courses for civilian laypeople.

Deep-Breathing Biofeedback Trainability in a Virtual-Reality Action Game: A Single-Case Design Study With Police Trainers

It is widely recognized that police performance may be hindered by psychophysiological state changes during acute stress. To address the need for awareness and control of these physiological changes, police academies in many countries have implemented Heart-Rate Variability (HRV) biofeedback training. Despite these trainings now being widely delivered in classroom setups, they typically lack the arousing action context needed for successful transfer to the operational field, where officers must apply learned skills, particularly when stress levels rise. The study presented here aimed to address this gap by training physiological control skills in an arousing decision-making context. We developed a Virtual-Reality (VR) breathing-based biofeedback training in which police officers perform deep and slow diaphragmatic breathing in an engaging game-like action context. This VR game consisted of a selective shoot/don’t shoot game designed to assess response inhibition, an impaired capacity in high arousal situations. Biofeedback was provided based on adherence to a slow breathing pace: the slower and deeper the breathing, the less constrained peripheral vision became, facilitating accurate responses to the in-game demands. A total of nine male police trainers completed 10 sessions over a 4-week period as part of a single-case experimental ABAB study-design (i.e., alternating sessions with and without biofeedback). Results showed that eight out of nine participants showed improved breathing control in action, with a positive effect on breathing-induced low frequency HRV, while also improving their in-game behavioral performance. Critically, the breathing-based skill learning transferred to subsequent sessions in which biofeedback was not presented. Importantly, all participants remained highly engaged throughout the training. Altogether, our study showed that our VR environment can be used to train breathing regulation in an arousing and active decision-making context.

Manipulating Stress Responses during Spaceflight Training with Virtual Stressors

Virtual reality (VR) provides the ability to simulate stressors to replicated real-world situations. It allows for the creation and validation of training, therapy, and stress countermeasures in a safe and controlled setting. However, there is still much unknown about the cognitive appraisal of stressors and underlying elements. More research is needed on the creation of stressors and to verify that stress levels can be effectively manipulated by the virtual environment. The objective of this study was to investigate and validate different VR stressor levels from existing emergency spaceflight procedures. Experts in spaceflight procedures and the human stress response helped design a VR spaceflight environment and emergency fire task procedure. A within-subject experiment evaluated three stressor levels. Forty healthy participants each completed three trials (low, medium, high stressor levels) in VR to locate and extinguish a fire on the International Space Station (VR-ISS). Since stress is a complex construct, physiological data (heart rate, heart rate variability, blood pressure, electrodermal activity) and self-assessment (workload, stress, anxiety) were collected for each stressor level. The results suggest that the environmental-based stressors can induce significantly different, distinguishable levels of stress in individuals.

A Reasonable Officer: Examining the Relationships Among Stress, Training, and Performance in a Highly Realistic Lethal Force Scenario

Under conditions of physiological stress, officers are sometimes required to make split-second life-or-death decisions, where deficits in performance can have tragic outcomes, including serious injury or death and strained police-community relations. The current study assessed the performance of 122 active-duty police officers during a realistic lethal force scenario to examine whether performance was affected by the officer's level of operational skills training, years of police service, and stress reactivity. Results demonstrated that the scenario produced elevated heart rates (i.e., 150 beats per minute), as well as perceptual and cognitive distortions, such as tunnel vision, commensurate with those observed in naturalistic use of force encounters. The average performance rating from the scenario was 59%, with 27% of participants making at least one lethal force error. Elevated stress reactivity was a predictor of poorer performance and increased lethal force errors. Level of training and years of police service had differential and complex effects on both performance and lethal force errors. Our results illustrate the need to critically reflect on police training practices and continue to make evidence-based improvements to training. The findings also highlight that while training may significantly improve outcomes, flawless performance is likely not probable, given the limits of human performance under stress. Implications for the objective reasonableness standard, which is used to assess the appropriateness of force in courts of law, are discussed.

Breathing Biofeedback for Police Officers in a Stressful Virtual Environment: Challenges and Opportunities

As part of the Dutch national science program “Professional Games for Professional Skills” we developed a stress-exposure biofeedback training in virtual reality (VR) for the Dutch police. We aim to reduce the acute negative impact of stress on performance, as well as long-term consequences for mental health by facilitating physiological stress regulation during a demanding decision task. Conventional biofeedback applications mainly train physiological regulation at rest. This might limit the transfer of the regulation skills to stressful situations. In contrast, we provide the user with the opportunity to practice breathing regulation while they carry out a complex task in VR. This setting poses challenges from a technical – (real-time processing of noisy biosignals) as well as from a user-experience perspective (multi-tasking). We illustrate how we approach these challenges in our training and hope to contribute a useful reference for researchers and developers in academia or industry who are interested in using biosignals to control elements in a dynamic virtual environment.

Stress-Activity Mapping: Physiological Responses During General Duty Police Encounters

Policing is a highly stressful and dangerous profession that involves a complex set of environmental, psychosocial, and health risks. The current study examined autonomic stress responses experienced by 64 police officers, during general duty calls for service (CFS) and interactions with the public. Advancing previous research, this study utilized GPS and detailed operational police records as objective evidence of specific activities throughout a CFS. These data were then used to map officers' heart rate to both the phase of a call (e.g., dispatch, enroute) and incident factors (e.g., call priority, use-of-force). Furthermore, physical movement (i.e., location and inertia) was tracked and assisted in differentiating whether cardiovascular reactivity was due to physical or psychological stress. Officer characteristics, including years of service and training profiles, were examined to conduct a preliminary exploration of whether experience and relevant operational skills training impacted cardiovascular reactivity. Study results provide foundational evidence that CFS factors, specifically the phase of the call (i.e., arrival on scene, encountering a subject) and incident factors (i.e., call priority, weapons, arrest, use-of-force), influence physiological stress responses, which may be associated with short-term performance impairments and long-term health outcomes. Implications of research findings for operational policing, police training, and health research are discussed.

Simulation Training Improves Resuscitation Team Leadership Skills of Nurse Practitioners

INTRODUCTION

In the current era of limited physician trainee work hours, limited nurse practitioner orientation times, and highly specialized care settings, frontline providers have limited opportunities for mentored resuscitation training in emergency situations. We aimed to evaluate the effectiveness of a pilot program to improve resuscitation team leadership skills of nurse practitioners using simulation-based training.

METHODS

Seven nurse practitioners underwent a 4-hour simulation course in pediatric cardiac emergencies. Pre- and post-course surveys were conducted to evaluate previous emergency leadership experience and self-reported comfort in the team lead role. The time to verbalization of a shared mental model to the team was tracked during the simulations.

RESULTS

The increases in self-reported comfort level in team leading, sharing a mental model, and differential diagnosis were statistically significant. Average time to shared mental model significantly decreased between simulations.

DISCUSSION

Simulation can improve code leadership skills of nurse practitioners. These preliminary findings require confirmation in larger studies.

The Human Factor: Optimizing Trauma Team Performance in Dynamic Clinical Environments

Resilience is built, not born, and there is no single strategy that reliably manufactures resilient performance in all circumstances. Optimizing team performance in dynamic environments involves the complex interplay of strategies that target individual preparation, team interaction, environmental optimization, and systems-level resilience engineering. To accomplish this, health care can draw influence from human factors research to inform tangible, practical, and measurable improvements in performance and outcomes, modified to suit local and domain-specific needs.

Comparison of Psychophysiological Stress in Physiotherapy Students Undertaking Simulation and Hospital-Based Clinical Education

INTRODUCTION

Simulation-based clinical education often aims to replicate varying aspects of real clinical practice. It is unknown whether learners' stress levels in simulation are comparable with those in clinical practice. The current study compared acute stress markers during simulation-based clinical education with that experienced in situ in a hospital-based environment.

METHODS

Undergraduate physiotherapy students' (n = 33) acute stress responses [visual analog scales of stress and anxiety, continuous heart rate (HR), and saliva cortisol] were assessed during matched patient encounters in simulation-based laboratories using standardized patients and during hospital clinical placements with real patients. Group differences in stress variables were compared using repeated measures analysis of variance for 3 time points (before, during the patient encounter, and after) at 2 settings (simulation and hospital).

RESULTS

Visual analog scale stress and anxiety as well as HR increased significantly from baseline levels before the encounter in both settings (all P < 0.05). Stress and anxiety were significantly higher in simulation [mean (SD), 45 (22) and 44 (25) mm; P = 0.003] compared with hospital [mean (SD), 31 (21) and 26 (20) mm; P = 0.002]. The mean (SD) HR during the simulation patient encounter was 90 (16) beats per minute and was not different compared with hospital [mean (SD), 87 (15) beats per minute; P = 0.89]. Changes in salivary cortisol before and after patient encounters were not statistically different between settings [mean (SD) simulation, 1.5 (2.4) nmol/L; hospital, 2.5 (2.9) nmol/L; P = 0.70].

CONCLUSIONS

Participants' experienced stress on clinical placements, irrespective of the clinical education setting (simulation vs. hospital). This study revealed that psychological stress and anxiety were greater during simulation compared with hospital settings; however, physiological stress responses (HR and cortisol) were comparable. These results indicate that psychological stress may be heightened in simulation, and health professional educators need to consider the impact of this on learners in simulation-based clinical education. New learners in their clinical education program may benefit from a less stressful simulation environment, before a gradual increase in stress demands as they approach clinical practice.

Efficacy of Stress Exposure Training on Target Acquisition in Combat Simulations

Transfer of training from simulators to real-world environments has recently come under investigation, as the generalizability of task-specific training has come into question. New hypotheses recommend that, to ensure effective performance under stress in real-world environments, one should supplement skill-based training with Stress Exposure Training (SET). Stress Exposure Training has further benefits in that it may serve as a more generalizable form of training and transfer across tasks and stressors. The impact of improving performance and reducing perceived stress and workload is of vital importance to many military operations, especially in high technology and high workload situations such as Landwarrior or Unmanned Arial Vehicles (UAVs; Mouloua, Hancock, & Gilson, 2003), in which mistakes are costly in terms of economics as well as life. In this paper the limits of SET transfer between laboratory training and field performance are investigated in regards to simulated combat target identification tasks.

The impact of personality traits and professional experience on police officers' shooting performance under pressure

We explored the impact of professional experience and personality on police officers' shooting performance under pressure. We recruited: (1) regular officers, (2) officers wanting to join a specialised arrest unit (AU) (expected to possess more stress-resistant traits; pre-AU) and (3) officers from this unit (expected to also possess more professional experience; AU) (all male). In Phase 1, we determined personality traits and experience. In Phase 2, state anxiety, shot accuracy, decision-making (shoot/don't shoot), movement speed and gaze behaviour were measured while officers performed a shooting test under low and high pressure. Results indicate minimal differences in personality among groups and superior performance of AU officers. Regression analyses showed that state anxiety and shooting performance under high pressure were first predicted by AU experience and second by certain personality traits. Results suggest that although personality traits attenuate the impact of high pressure, it is relevant experience that secures effective performance under pressure. Practitioner Summary: To obtain information for police selection and training purposes, we let officers who differed in personality and experience execute a shooting test under low and high pressure. Outcomes indicate that experience affected anxiety and performance most strongly, while personality traits of thrill- and adventure-seeking and self-control also had an effect.

Towards immersive virtual reality (iVR): a route to surgical expertise

Surgery is characterized by complex tasks performed in stressful environments. To enhance patient safety and reduce errors, surgeons must be trained in environments that mimic the actual clinical setting. Rasmussen’s model of human behavior indicates that errors in surgical procedures may be skill-, rule-, or knowledge-based. While skill-based behavior and some rule-based behavior may be taught using box trainers and ex vivo or in vivo animal models, we posit that multimodal immersive virtual reality (iVR) that includes high-fidelity visual as well as other sensory feedback in a seamless fashion provides the only means of achieving true surgical expertise by addressing all three levels of human behavior. While the field of virtual reality is not new, realization of the goals of complete immersion is challenging and has been recognized as a Grand Challenge by the National Academy of Engineering. Recent technological advances in both interface and computational hardware have generated significant enthusiasm in this field. In this paper, we discuss convergence of some of these technologies and possible evolution of the field in the near term.

The moderating effect of individual differences in error-management training: who learns from mistakes?

OBJECTIVE

We investigated the effectiveness of error-encouragement training and the influence of ability and personality attribute-treatment interactions using a dynamic decision-making task.

BACKGROUND

Error-encouragement training is said to be more effective than error-avoidance training because active exploration and error encouragement promote better learning and transfer. Past research, which is limited by confounded experimental designs involving simple tasks with little consideration of individual differences, provides evidence for the value of active exploration but less so for error encouragement

METHOD

We randomly allocated 164 participants to receive error-encouragement, error-avoidance, or no error-related instructions in training on ATC-lab, a dynamic computer simulated air traffic control task. Active exploration and task information were controlled, and ability and personality were assessed.

RESULTS

Error encouragement yielded better transfer performance than did error avoidance but was no better than the control training. Higher- rather than lower-ability trainees benefited from training with an error orientation (positive or negative), suggesting that learning from errors in training requires greater cognitive resources. Trainees higher in openness to experience and agreeableness performed more poorly with error-avoidance training than with error-encouragement and control training.

CONCLUSION

Error-avoidance training had a detrimental effect especially for those less open to experience, lower in agreeableness, and of lower ability. The significant benefits of error-encouragement training reported in previous research were probably attributable to confounding factors, such as active exploration and differential task information.

APPLICATION

Although errors and active exploration can be useful learning tools in training, trainers should be mindful that focusing on errors, whether positively or negatively, may not suit everyone.

Phased training for high-reliability occupations: live-fire exercises for civilian firefighters

OBJECTIVE

The aim of this study was to assess whether the stress reduction effects of phased training culminating in repeated exposure to a stressful scenario generalize to new scenarios.

BACKGROUND

High-reliability occupations require personnel to operate in stressful situations involving complex environments, high degrees of uncertainty and time pressure, and severe consequences for mistakes. One method of training for such environments culminates in practice in high-fidelity, highly stressful simulations. For some domains, realism necessitates large-scale, difficult-to-modify physical simulations. This necessity often results in repeated exposure to one or very few scenarios. The literature gives reason to question whether the stress reduction effects of such exposure transfer to new scenarios.

METHOD

Anxiety and cognitive difficulties were measured among firefighter trainees during three live-fire drills. For each trainee, two drills involved the same scenario, and the other involved a new scenario that was structurally similar to the repeated scenario.

RESULTS

As predicted, anxiety and cognitive difficulties decreased across repetitions of the same scenario. However, the reduction did not generalize to a new scenario, and a nontrivial portion of the sample showed signs of negative transfer.

CONCLUSION

Repeated exposure to the same stressful scenario as the final phase of training has limited practical value for stress reduction. Methods for expanding the range of scenarios to which trainees are exposed or for increasing the value of the exposure are recommended.

APPLICATION

The findings could help improve design of training programs for high-reliability occupations.

Stress training improves performance during a stressful flight

OBJECTIVE

This study investigated whether stress training introduced during the acquisition of simulator-based flight skills enhances pilot performance during subsequent stressful flight operations in an actual aircraft.

BACKGROUND

Despite knowledge that preconditions to aircraft accidents can be strongly influenced by pilot stress, little is known about the effectiveness of stress training and how it transfers to operational flight settings.

METHOD

For this study, 30 participants with no flying experience were assigned at random to a stress-trained treatment group or a control group. Stress training consisted of systematic pairing of skill acquisition in a flight simulator with stress coping mechanisms in the presence of a cold pressor. Control participants received identical flight skill acquisition training but without stress training. Participants then performed a stressful flying task in a Piper Archer aircraft.

RESULTS

Stress-trained research participants flew the aircraft more smoothly, as recorded by aircraft telemetry data, and generally better, as recorded by flight instructor evaluations, than did control participants.

CONCLUSIONS

Introducing stress coping mechanisms during flight training improved performance in a stressful flying task.

APPLICATION

The results of this study indicate that stress training during the acquisition of flight skills may serve to enhance pilot performance in stressful operational flight and, therefore, might mitigate the contribution of pilot stress to aircraft mishaps.

Where's the emotion? How sport psychology can inform research on emotion in human factors

OBJECTIVE

The aim of this study was to demonstrate how research on emotion in sport psychology might inform the field of human factors.

BACKGROUND

Human factors historically has paid little attention to the role of emotion within the research on human-system relations. The theories, methods, and practices related to research on emotion within sport psychology might be informative for human factors because fundamentally, sport psychology and human factors are applied fields concerned with enhancing performance in complex, real-world domains.

METHOD

Reviews of three areas of theory and research on emotion in sport psychology are presented, and the relevancy of each area for human factors is proposed: (a) emotional preparation and regulation for performance, (b) an emotional trait explanation for risk taking in sport, and (c) the link between emotion and motor behavior. Finally, there are suggestions for how to continue cross-talk between human factors and sport psychology about research on emotion and related topics in the future.

RESULTS

The relevance of theory and research on emotion in sport psychology for human factors is demonstrated.

CONCLUSION

The human factors field and, in particular, research on human-system relations may benefit from a consideration of theory and research on emotion in sport psychology.

APPLICATION

Theories, methods, and practices from sport psychology might be applied usefully to human factors.

Training with anxiety: short- and long-term effects on police officers' shooting behavior under pressure

We investigated short- and long-term effects of training with anxiety on police officers’ shooting behavior under pressure. Using a pretest, posttest, and retention test design, 27 police officers executed a shooting exercise against an opponent that did (high anxiety) or did not (low anxiety) shoot back using colored soap cartridges. During the training sessions, the experimental group practiced with anxiety and the control group practiced without anxiety. At the pretest, anxiety had a negative effect on shot accuracy for both groups. At the posttest, shot accuracy of the experimental group no longer deteriorated under anxiety, while shot accuracy of the control group was still equally affected. At the retention test, 4 months after training, positive results for the experimental group remained present, indicating that training with anxiety may have positive short- and long-term effects on police officers’ shot accuracy under pressure. Additional analyses showed that these effects are potentially related to changes in visual attention on task-relevant information.

Simulation-based education for building clinical teams

Failure to work as an effective team is commonly cited as a cause of adverse events and errors in emergency medicine. Until recently, individual knowledge and skills in managing emergencies were taught, without reference to the additional skills required to work as part of a team. Team training courses are now becoming commonplace, however their strategies and modes of delivery are varied. Just as different delivery methods of traditional education can result in different levels of retention and transfer to the real world, the same is true in team training of the material in different ways in traditional forms of education may lead to different levels of retention and transfer to the real world, the same is true in team training. As team training becomes more widespread, the effectiveness of different modes of delivery including the role of simulation-based education needs to be clearly understood. This review examines the basis of team working in emergency medicine, and the components of an effective emergency medical team. Lessons from other domains with more experience in team training are discussed, as well as the variations from these settings that can be observed in medical contexts. Methods and strategies for team training are listed, and experiences in other health care settings as well as emergency medicine are assessed. Finally, best practice guidelines for the development of team training programs in emergency medicine are presented.

“People as Technology” Conceptual Model: Toward a New Value Creation Paradigm for Strategic Human Resource Development

This article proposes a “people as technology” (PT) conceptual model that introduces five key values providing connections of human resource development and technology development: location, use, maintenance, modification, and time. The PT conceptual model provides a scheme for identifying how HRD and technology development may change and/or mediate the relationship between organization employees and leaders. The relationships between people and technology can be better managed through the cognitive, behavioral, and/or cultural perspectives of the organization, create five key values, and produce competitive advantage for organizations.The PT conceptual model provides a theoretical framework for further research and practical applications of management practices, training practices, HRD philosophy, and HRD strategies within organizations.

The effects of acute stress on performance: implications for health professions education

PURPOSE

This paper is a review of representative research on the impact of acute stressors on the clinical performance of individuals and teams.

METHOD

The Sciences Citation Index, Medline, and Psychinfo were used to search for articles up to and including 2008. The search terms were stress/tension/arousal/anxiety/cortisol/threat, cognition/skills/memory/attention/problem solving/decision making/performance, stress reduction/stress exposure/stress management/stress inoculation, and health professionals/medicine/medical students/residents/physicians/teams. The search was limited to papers in English from all developed countries. Secondary references were selected from primary papers.

RESULTS

Elevated stress levels can impede performance on tasks that require divided attention, working memory, retrieval of information from memory, and decision making. These effects appear to be determined by the individual's appraisal of the demands and resources of a situation, the relationship between the stressor and the task, and factors such as coping styles, locus of control, and social supports.

CONCLUSIONS

Given the potential negative impact of stress on performance, and the individualistic way in which people respond, medical educators might want to consider avenues for training learners in stress management. More research is needed to fully understand the contributions of personal factors such as coping style and locus of control, as well as the relationship of perceptions of stress to issues such as fatigue.

Benefits of training and development for individuals and teams, organizations, and society

This article provides a review of the training and development literature since the year 2000. We review the literature focusing on the benefits of training and development for individuals and teams, organizations, and society. We adopt a multidisciplinary, multilevel, and global perspective to demonstrate that training and development activities in work organizations can produce important benefits for each of these stakeholders. We also review the literature on needs assessment and pretraining states, training design and delivery, training evaluation, and transfer of training to identify the conditions under which the benefits of training and development are maximized. Finally, we identify research gaps and offer directions for future research.

The search for complex problem-solving strategies in the presence of stressors

OBJECTIVE

The present research tests the effects of time pressure and noise on open-mindedness to discover new problem-solving strategies.

BACKGROUND

We are primarily interested in transfer of skill from one phase to the next. More specifically, this study investigates whether the presence of stressors makes participants adhere to the sustained use of complex rules.

METHOD

Participants learned to apply a complex rule in the first phase of a category learning task. In the second phase, this rule became dysfunctional and participants had to search for a new categorization rule in order to assign the stimuli to the correct classes. Two experiments were set up to investigate this issue.

RESULTS

Participants were found to have difficulty discovering a complex Phase 2 rule in the presence of stressors, whereas the discovery of a simple rule was not hindered by the presence of stressors.

CONCLUSION

In the discussion, it is argued that the present results are compatible with previous research on stressors showing that time pressure and noise induce the application of simple strategies. The innovative finding here is that this simplification also occurs in individuals who are accustomed to using complex solutions.

APPLICATION

The implications of the present results for emergency response training are elaborated upon.

The effects of examination stress on the performance of emergency medicine residents

CONTEXT

Despite the finding that residents are exposed to significant stressors during their training, little is known about the impact of these stressors on performance. The objectives of this project were to measure the subjective anxiety felt by emergency medicine (EM) residents during in-training examinations, and to determine the effect of this anxiety on their ability to diagnose visual stimuli such as X-rays, photographs and electrocardiographs.

METHODS

Two examinations, matched for difficulty and length, were constructed based on the performance of 23 residents in 2 Royal College of Physicians and Surgeons of Canada (RCPSC) EM residency programmes. These examinations were then administered at 2-week intervals to another 24 residents in 2 additional RCPSC EM programmes. One examination was administered under high-stress conditions (in-training examination) and the other under low-stress (control) conditions. Perceived anxiety was measured using the state scale of the State-Trait Anxiety Inventory before and after each iteration of the examination.

RESULTS

Residents reported higher levels of anxiety in the high-stress condition (41.5 versus 35.9, P < 0.05). Examination scores were higher in the high-stress condition (70.4 versus 64.4, P < 0.01). The scores of junior residents improved in the high-stress condition, whereas those of intermediate and senior residents did not change.

CONCLUSIONS

Emergency medicine residents report higher anxiety during in-training examinations compared with control conditions. Residents at all levels exhibited similar perceptions of anxiety. Junior residents performed better under stress, achieving higher scores during the in-training examination than during the control condition. The performance of more experienced residents was not affected by the stress condition.

Adaptability of training in simulated process control: knowledge- versus rule-based guidance under task changes and environmental stress

OBJECTIVE

The study examined the adaptability of different types of process control training across changes in task and environmental stress.

BACKGROUND

The literature on training leads us to expect greater flexibility for system-based training, as opposed to procedure-based training. However, the stress literature suggests that knowledge-based strategies (making use of executive control) may be more vulnerable under stress conditions.

METHOD

Two groups were given 6 hr of training on the Cabin Air Management System (CAMS), a complex, multilevel, PC-based process control task, emphasizing either system knowledge or use of procedures. They were then required to carry out the task for 3 hr (with noise during the middle 1 hr) across a range of both familiar and unfamiliar fault scenarios.

RESULTS

For the primary control task, the system-trained group performed better, especially for less familiar and complex faults. However, for lower priority tasks requiring executive control, procedure-trained operators performed better and were less impaired by noise.

CONCLUSION

System training was more effective for managing unexpected task events, whereas procedural training was better under noise. The results are interpreted in terms of the rationale for instructing operators in the range of strategies required for effective process skills in complex work environments.

APPLICATION

Training methodologies for safety critical applications should aim to develop skill in the use of both procedural and system knowledge strategies. Operators should be trained in the most effective deployment of these strategies during unfamiliar task events and environmental stress and given stress exposure training.

How to turn a team of experts into an expert medical team: guidance from the aviation and military communities

There is no question that interdisciplinary teams are becoming ubiquitous in healthcare. It is also true that experts do not necessarily combine to make an expert team. However when teams work well they can serve as adaptive systems that allow organisations to mitigate errors within complex domains, thereby increasing safety. The medical community has begun to recognise the importance of teams and as such has begun to implement team training interventions. Over the past 20 years the military and aviation communities have made a large investment in understanding teams and their requisite training requirements. There are many lessons that can be learned from these communities to accelerate the impact of team training within the medical community. Therefore, the purpose of the current paper is to begin to translate some of the lessons learned from the military and aviation communities into practical guidance that can be used by the medical community.

How to turn a team of experts into an expert medical team: guidance from the aviation and military communities

There is no question that interdisciplinary teams are becoming ubiquitous in healthcare. It is also true that experts do not necessarily combine to make an expert team. However when teams work well they can serve as adaptive systems that allow organisations to mitigate errors within complex domains, thereby increasing safety. The medical community has begun to recognise the importance of teams and as such has begun to implement team training interventions. Over the past 20 years the military and aviation communities have made a large investment in understanding teams and their requisite training requirements. There are many lessons that can be learned from these communities to accelerate the impact of team training within the medical community. Therefore, the purpose of the current paper is to begin to translate some of the lessons learned from the military and aviation communities into practical guidance that can be used by the medical community.