This document discusses stress inoculation training (SIT), a cognitive behavioral therapy technique used to help individuals cope with stress. SIT involves 3 phases: 1) education about stress responses, 2) skills acquisition like coping mechanisms, and 3) applying skills through graduated exposure to stress. The goal is to "inoculate" trainees by exposing them to mild stressors so they can perform skills even when stressed. SIT has been used in military, NASA, and is starting to be applied to medical education to improve performance in emergency situations.

1. Jeremy Mason
ED Registrar SCGH
Thursday 18th February 2016

2.  The process of showing people what can
happen to you under stress
 Developing and building tools to cope with
the physiological response to stress
 “Innoculating” by exposing yourself to the
stressors that you’re likely to experience in
your field

3.  1) To gain knowledge and familiarity with a
stressful environment
 2) To develop and practice task-specific
skills, including psychological skills as well as
decision making faculties, to be performed
under stress
 3) To build confidence in an individuals
capabilities

4.  Simple message; How you train is how you fight
 Tachycardia can make you stupid
 If you let your vital signs and catechloamine surge
over take your cognitive ability – it will completely
ruin your ability to manage a stressful situation
 You will encounter stress and its negative effects
taking care of critically ill or injured patients
 Preparation is required to perform at your very best

5.  Developed by psychologist Donald Meichenbaum in 1980’s
 Multifaceted type of Cognitive Behavioural Therapy designed to help
individuals cope with stress
 Based on the concept of inoculation – prepares a person to be more
resistant to stress through prior exposure to milder forms of stress
 Widely used by Military and NASA to mitigate stress in a variety of
situations
 Psychological technique used in PTSD, anxiety and anger
 Starting to be used in medical education to help improve performance in
emergency and critical care
 Dedicated EMCRIT & iTeachEM Podcasts on the topic + dedicated
preconference workshop at SMACC Chicago 2015

6.  Based on appraisal and coping behaviour
◦ We experience stress when we evaluate the
relationship we have with our environment as
being:
 Over demanding
 Beyond our ability to cope with
 Posing a threat to our health and wellbeing

7.  We construct stories about ourselves
 These stories affect persons ability to cope
with stress
 Being a “Victim” vs being and “Overcomer”
 SIT uses this perspective to help people
construct life narratives to help them cope
with stress

8.  SIT teaches a broad
range of coping skills
 These coping skills can
be applied in any
stressful situation
 SIT comprises 3
overlapping phases

9.  Phase 1 – Information Provision
◦ Learns about the nature and impact of the human stress
response
◦ Made aware of their ability to solve problems
◦ Encouraged to think adaptively
 Phase 2 – Skills acquisition
◦ Develops and refines behavioural, technical & cognitive skills
 Phase 3 – Application and practice
◦ Practice skills learnt
◦ Graded exposure to increasingly stressful situations

10.  Educational phase
 Show people the physiological response to stress
 There’s a difference between having knowledge stored in
your memory and having the ability to apply that
knowledge and get things done when you’re stressed or
when things aren’t going well
 Same applies with technical skills e.g. Intubating a
mannequin in a quiet room vs massive haematemesis with
SATS dropping
 Tell people there’s a way to improve your performance

11.  Grossman & Sidel 1996 review– Examined combat
and the warrior mindset
 Used heart rate as a surrogate for amount of stress
 Looked at skills performance and how people
respond
 Found an “ideal” level of arousal
 As stress increased there was a point where they
became overloaded and experienced a deterioration
in cognitive and skills performance

12. http://www.thinklikeahorse.org/flight_or_fight.html

14. https://www.adelaide.edu.au/uni-thrive/revive/stress/

15. From On Combat, by Lt. Col Dave Grossman

16.  Building skills and muscle memory to perform
skills when it really counts
 Develop technical & non technical skills
needed to perform in the resus environment
without the addition of stressful stimuli
 Goals:
◦ Learn & develop constructive coping mechanisms
◦ Develop effective performance habits

17. Think Feel Act
 Provide control over distracting or stress inducing
thoughts
 Individual is taught to recognize distracting thought
processes and stop them

18. Negative
thought
STOP
Replace with
positive, task-
focused
thoughts

19.  Controlling specific physiological parameters
 Progressive relaxation
◦ Not always feasible when faced with deteriorating patient
 Controlled breathing
◦ Respiration is the only autonomic function that can be controlled and
modified consciously
◦ Can be used to control emotional response
◦ Slow breathing  Reduced heart rate  Reduced stress
◦ Seppala et al 2014 RCT
 Breathing techniques decrease stress response, anxiety and hyper arousal in
combat veterans with PTSD
◦ Tactical breathing – 4 second method

20.  “The same neural pathways are recruited and
the same neurochemicals are secreted when
we visualize doing something as when we
engage in the actual acivity” 1
 Lorello 2015 – Mental practice is effective at
preparing teams for trauma resuscitation
◦ 20 mins mental practice vs 20 mins ATLS Sim
◦ Mental practice group increased scores for
teamworking behaviours
1 Weisinger H, Pawliw-Fry JP. Performance Under Pressure. New York, NY: Crown Business; 2015
2 Lorello, G. R., Hicks, C. M., Ahmed, S.-A., Unger, Z., Chandra, D., & Hayter, M. A. (2015). Mental practice: a
simple tool to enhance team-based trauma resuscitation. Canadian Journal of Emergency Medicine, FirstView,
1–7.

21.  Training decision making skills
◦ Eg algorithms and checklists
 Overleaning technical skills
 Teaching on communication
 Team training / simulations

22.  Take skills from Phase 2 and rehearse them in
increasingly graduated stressful conditions
 Allows trainees to experience in real time the
performance challenges they will face in a
specific setting
 Reduces uncertainty and anxiety
 Increases confidence when individuals realise
they can overcome stressors

23.  1) Performance diminishes under stress
 2) Technical skill & knowledge necessary but not
enough to perform effectively in stressful
situations
 3) Focus on developing the skills to perform
under stress
 4) No RCTs yet exploring SIT in resuscitation –
some currently under way but needs further
investigation

24.  iTeachEM Podcast by Rob Rogers, Stress Inoculation
Training http://iteachem.net/2014/12/stress-
inoculation-training/
 http://emcrit.org/blogpost/on-stress-inoculation-
training/
 http://emcrit.org/blogpost/performance-enhancing-
psychological-skills/
 http://emcrit.org/blogpost/flow/
 https://www.adelaide.edu.au/uni-
thrive/revive/stress

25.  Weisinger H, Pawliw-Fry JP. Performance Under Pressure.
New York, NY: Crown Business; 2015
 Lorello, G. R., Hicks, C. M., Ahmed, S.-A., Unger, Z.,
Chandra, D., & Hayter, M. A. (2015). Mental practice: a
simple tool to enhance team-based trauma
resuscitation. Canadian Journal of Emergency
Medicine, FirstView, 1–7.
 M Seppälä, E., B Nitschke, J., L Tudorascu, D., Hayes, A., R
Goldstein, M., T H Nguyen, D., … J Davidson, R. (2014).
Breathing-Based Meditation Decreases Posttraumatic
Stress Disorder Symptoms in U.S. Military Veterans: A
Randomized Controlled Longitudinal Study. Journal of
Traumatic Stress, 27(4), 397–405