Author: Charlotte Davies / Editor: Liz Herrieven / Codes: SLO11, SLO2, SLO8, SLO9 / Published: 30/04/2019


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In simulation scenarios, people often say that they felt “stressed”. So, how do we manage this “acute stress”? Counselling and psychotherapy aren’t what’s needed for most people and the acute stress response may even be beneficial. Here are the suggestions we give in our simulation debrief – I’d love to hear any more.

Nuts – Training – Stress – Step 1 – 2 – 3

1. “Nuts”

Recognise your stressors. What stresses you out? Things normally fit into four broad categories: “NUTS”. Novelty, Unpredictability, Threat to Ego and Sense of Control Loss. Once you’ve identified your stressors, can you reduce them?

2. Stress Innoculation Exposure Training

Educate yourself on how to deal with stress, practice stressful situations, prepare yourself, and then apply it.


Self Aware – Acknowledge you are stressed. Let your team know. You may need to look for the “BEST” signs of stress – Behavioural fight and flight, Emotional anger and irritability, Somatic sweating, Thinking and tunnel vision. We know that Stress can be good for us – the mix of skill and challenge helps us to be “in the flow”. But too much stress and our cognitive processing deteriorates.

Take Ten – No-one dies because you spent ten seconds taking a breath in. Use this time to gather your thoughts. This might be a mental pause, or a physical pause where you take yourself out of the situation.

Relaxation Techniques – this could be physiological or cognitive relaxation.  Do some square (or tactical) breathing – breathe in through your nose for four seconds, hold for four, exhale for four, hold for four. This is a more focussed strategy than “take a deep breath” and seems to work more effectively.
Cognitively relax by reminding yourself that stress is good. Say hello to stress! We all know that optimal arousal (not too low, not too high) can lead to optimal performance – stand up straight (utilising positive body language) and embrace it!

Evaluate Stressors – and remove them if possible. It might be that you are “HALT” (hungry, angry, late or tired) and most of these are easily remedied. You might need to message someone you’ve argued with and tell them you love them to stop it playing on your mind and contributing to your stress. You might need to eat.

Support – ask for help from senior and junior colleagues including different specialties and different professions.

Self Care – build your resilience.

4. Debrief and Consider

Always debrief after an incident, whether you found it stressful or not. Think about why you found it stressful or why you didn’t. Leave it behind when you leave work – remember to checkout!

Checking out is all part of your emotional hygiene – something that should be as regular as washing your hands!

5. Build your Resilience

Resilience isn’t how much it takes to break you, it’s how quickly you bounce back after being broken. Palm trees are very resilient – the wind blows them nearly horizontal, but they spring back up again. In medicine our wind is constantly blowing us over – we do need to stop the wind, as well as springing up afterwards. Being resilient doesn’t solve everything wrong with the world – but whilst we wait for efforts for the wind to stop blowing, we need to make sure we’ve found shelter.

There’s lots of different components to being resilient, and you need to look at all of them. You need to reach “ikigai” and balance out what you are good at with what you love, pay, and what the world needs.

Here are some practical tips to help you address all those areas:

a) Lifestyle

– Practice straightforward communication with people, and saying what you mean.
– Practice “kindfullness
– Relax and enjoy things. If you couldn’t do it without your professional registration, it’s not relaxing.
– Make time for your friends and family.
– Book a holiday so you can always move, like Tarzan, from one holiday to the next.
– If you need personal or relationship counselling, as suggested in this journalfeed, get it.

b) Physical Health – “REST”

– Regular breaks – on shift and off shift
– Eat Well
– Sleep well
– Train / Exercise

c) Give yourself a break

– Reward achievement – congratulate yourself on the things you’ve done well.
– Book a holiday – make sure you can swing from one holiday to another.
– Resolve conflicts in your professional and personal life.
– Out-source anything that you can. Get a cleaner. Accept help from your friends. Get a gardener. Stanford hospital pays overtime not only in monetary terms, but in “out-sourcing” terms. If you work overtime, you get meals provided or your washing done.
– Don’t sweat the small stuff. It’s annoying when things don’t go to plan, but is it helpful for you to try and make it better?

d) Look after your own mental health

– Be positive and look for the silver lining. This website has some great happy links!
– Use humour
– Give things a lack of permanence “my boss didn’t like that piece of work” is better than “my boss never likes my work”.
– Identify your “addiction”. This might be drugs and alcohol, or you might be a:
* care-aholic – worrying about others instead of yourself
* busy-aholic – always involved in something, but may not engage meaningfully with this
* work-aholic – high risk for developing burnout or rust-out
* rush-aholic – speeding around, not noticing natural beauty. Risk of burnout or rust- out

e) Appraisal and Support

– Talk about appraisal and make sure it happens. The EMJ 2015 supplement has some great tips for this here.
– Tell your friends what’s happening
– Use all your resources
– Share your experiences

If you feel you or a colleague may be suffering from compassion fatigue, or burnout – identify it, and seek help from collegues and professional services. If it’s not quite burnout yet, it might be “rust-out” – wonderfully described in “Challenging Stress, Burnout and Rust-Out“.

Stress, Resilience and Wellbeing are big topics at the moment – rightly so. There’s lots of references below – add your favorites in the comments. There’s no “one size fits all” approach.

AACN Advanced Critical Care Writing a Simulation Scenario

Medical Education 2015: 49: 576–588

Going DEEP: guidelines for building simulation-based team assessments

Incorporating Quality and Safety Education for Nurses Competencies in Simulation Scenario Design

The Template of Events for Applied and Critical Healthcare Simulation

Microteach: Resilience and stress.
Mind Tips
Strength of Resilience
Signs of Burnout
Tips for Mental Health
Sleep Hygiene
Stanford Experience
Building Resiliency
Growing to be Happy
EMJ Supplement 1 and 2
Stress Website
Make stress your friend
Understanding Stress
Coping with stress
Reduce Stress