Peak performance under pressure

Luca Carenzo
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Considerations on the role of simulation in the assessment and training of health professionals exposed to stressful situations

In the world of emergency-urgency, it often happens that you find yourself managing stressful situations and having to make a large number of decisions under pressure and in the shortest time possible.

Imagine being the leader of a trauma team facing pediatric traumatic cardiac arrest, or facing a situation where you can’t intubate and can’t ventilate while managing an elective airway. How do your mind and body react in these contexts? Do you think you would be able to stay lucid? They are definitely stressfulsituations.

How do we assess the situation?

The individual response to stress is strongly influenced by the assessment of the situation in which we find ourselves. First, we assess what is required of us to accomplish a goal. Next, we evaluate the personal and environmental resources we have to achieve this goal. The resources we draw on are mental resources, not manual skills like the ability to intubate. To make a sport psychology comparison, we are not asking a tennis player in the Wimbledon final if he can play tennis, but if he feels he has the resources to face the final and win it.

When resources are sufficient to meet demand, we frame the situation as challenging and a positive psychological state of “eustress” ensues that supports optimal performance. When requests exceed resources, we perceive a threat and therefore a sense of danger that can compromise our performance. The response of each of us to different situations is subjective and is based on the individual perception of requests and resources. Any factor that, in our judgment, increases demand or decreases available resources increases the risk of developing a negative stress response.

But what is stress?

There is no single definition of stress in the literature. However, we believe that anyone who practices medicine, especially in the emergency field, is well aware of the meaning of this word. However, it is important to remember that although we generally refer to stress with a negative meaning, it is our body’s response to stress that can be such. Without the stress factor, our emergency response would likely be ineffective. What makes it harmful are the emotions associated with it, if they arise with excessive intensity, frequency or duration, or if they are inappropriate for the type of situation.

Stress and Simulation

Given these premises, it is not difficult to imagine the role of simulation in the evaluation and training of health professionals exposed to stressful situations.

During SIMCUP Italy 2018, we submitted all participants to a self-assessment questionnaire, in which they were asked to express how demanding they perceived the emergency simulation scenarios to be and how much they felt they had the resources to face them successfully. We then collected the instructors’ evaluations of the individual participants’ and teams’ performance within the scenario, and by combining all the data, we built a linear model that describes the performance trend as changes in the participants’ cognitive perception of stress. The model suggests that a high level of resources is associated with better performance until the demands become very high. It is very interesting to consider that with specific interventions, also through simulation training, it is possible to manipulate the perception of resources and then check if this translates into an improvement in performance. There is certainly room for future research projects in this field.

And to know more?

The sixteenth edition of the Trauma Update congress will take place in Bologna on March 31 and April 1 and 2. On March 31, a Simulation masterclass on advanced management of prehospital trauma will be held and each scenario will be addressed with the implications of cognitive assessment theories in mind, with the aim of improving the participants’ ability to transform threateningsituations into challenges. The masterclass is already completely sold out, but don’t despair! On the afternoon of April 1 we will have a session entirely dedicated to the psychology of performance applied to medicine. A highly respected international guest will be with us: Dr. Steven Hearns, Scottish Helicopter Rescue Physician and author of the book Peak Performance Under Pressure


Carenzo L, Braithwaite EC, Carfagna F, et al. Cognitive appraisals and team performance under stress: A simulation study.

Med Educ. 2020;54(3):254-263. doi:10.1111/medu.14050

Meijen C, Turner M, Jones MV, Sheffield D, McCarthy P. A Theory of Challenge and Threat States in Athletes: A Revised Conceptualization.

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Luca Carenzo

Luca Carenzo

Dipartimento di Anestesia e Rianimazione, IRCCS Humanitas Research Hospital, Rozzano, Milano View all Posts
Lorenzo Gamberini

Lorenzo Gamberini

Anestesia, Rianimazione ed Emergenza Territoriale, Ospedale Maggiore Carlo Alberto Pizzardi, Bologna View all Posts

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