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Acute stress prevention

As was the case with chronic stress, it is possible to distinguish between primary, secondary and tertiary stress preventative methods for acute stress.

Primary prevention

Many jobs in high-reliability industries involve, at least occasional, periods of high stress, and removing the stressors may be impossible. For example, when one of the authors of this book was interviewing an anaesthetist about his job, he was told that it is 95% complete boredom and 5% sheer panic. Therefore, as was the case with the primary prevention of chronic stress, people who perform jobs where they may be exposed to acute stress must have adequate professional training and experience, so that they are less likely to experience acute stress.

Secondary prevention

Secondary acute stress prevention is concerned with the prompt detection and management of the symptoms and effects of stress. Diagnosis that a debilitating stress reaction is being experienced by oneself or by other team members is a fundamental starting point in stress management. Self-awareness of stress reactions

is as essential as recognition of stress reactions in others. All members of any organisation where stressful responses may arise should therefore be trained to take the necessary action of drawing the team leader’s attention to any other member who exhibits symptoms of stress that are causing distress or are detrimental to his or her performance. This includes telling the leader when he or she is not coping well with a stressful situation.

Personnel exhibiting a severe negative response reaction should be switched to a non-essential task and kept under observation, but should be treated as if he or she were having a normal reaction and, if possible, kept with the team (Hodgkinson and Stewart, 1991).

Training individuals for stress reactions can take the form of general exercises, or more specific techniques for coping with stress reactions. Building experience, particularly of stressful situations, creates greater self-confidence and therefore reduces the likelihood of stress occurring in the first place.

The importance of training for stress-proofing personnel cannot be overemphasised. Realistic exercises and simulator sessions, i.e. being prepared through practical exercises, are a major stress-reduction mechanism (Hytten and Hasle, 1989). Training of the required emergency response procedures can be employed to ensure effective performance under stress conditions, as well as the use of case studies and presentations by experienced personnel. Knowledge and awareness of the potential causes of emergencies and stressors, and how to deal with them, introduced in training sessions, will assist in minimising negative stress reactions.

Johnston and Cannon-Bowers (1996) describe a three-stage training process designed to improve team performance in stressful situations called stress exposure training. In the first phase the trainees are provided with knowledge about the causes and reactions to acute stress (as outlined earlier in this chapter). In the second phase the trainees are given training designed to help the participants cope with stress through practice and feedback. Driskell et al. (2001) outline a variety of stress management approaches that could be used to reduce the negative effects of stress on performance, both for the individual and team. The most appropriate training technique (or techniques) is dependent on the task and a training needs analysis can be used to identify the areas in which training is required:

  • Cognitive control techniques. The purpose of this type of technique is to train individuals to regulate emotions (e.g. worry) and regulate distracting thoughts to allow them to maintain concentration on the task. This may include stepping away from the situation for a couple of minutes if they start to feel overwhelmed, or providing a procedure to regulate stress reactions, for example:
  • • STOP - Stand back, Take stock, Overview, Procedures
  • • STAR - Stop, Think, Act, Review
  • • or for decision-making, DODAR - .Diagnose, Options, Decide, A ssign and Review).
  • Physiological control techniques. This technique attempts to provide methods for regulating the negative physiological reactions to stress. It attempts to

allow an individual to be calm, relaxed and under control when faced with an emergency. Okray and Lubnau (2004) describe a fire department chief who teaches firefighters to be aware of their heart rate. He believes that if the firefighter’s heart is beating 90-110 beats per minute, with no exertion, then he or she needs to take a few deep breaths and think about what is happening. If his or her heart is beating at greater than 110 beats per minute, without exertion, he or she needs to take a few steps back, calm down and regain concentration. Singapore police use several ‘stress blasting techniques’ for combating operational stress, including ‘tactical breathing’, which involves slow, deep breaths.

  • Modelling. In this method the trainees are given the opportunity to observe or model a team responding to a high-stress situation. It is postulated that this gives the trainees the opportunity to observe good, or bad, examples of key behaviours in a realistic setting.
  • Overlearning. In this training method the trainees are deliberately overtrained beyond a level of proficiency that would normally be required for a particular task. For this method to be effective in a real-life situation, Driskell et al. (2001) recommend that the task trained must be the same as that which would be performed in a high-stress situation, and it should be practised in a simulated stressful environment.
  • Attentional training. This type of training educates the trainees as to when, how and why attention may be distracted when performing a task during a highly stressful situation. The aim is to overcome the effects of perceptual tunnelling and distractions that occur in a stressful environment.
  • Training time-sharing skills. Often in emergency situations, it is necessary for the team members to carry out multiple tasks simultaneously. Therefore, trainees are given the opportunity to perform the tasks and provided with skills to prioritise the importance of the tasks.
  • Decision-making training. This training can be given for skills that are particularly vulnerable to the effects of stress, e.g. decision-making and communication. The inclusion of material on decision strategies, how to build shared mental models, communication and command and control in training, using some type of scenario-based practice strategy, could provide a vehicle to demonstrate and reinforce desired behaviours (see Chapter 10).
  • Enhancing flexibility. As outlined in Table 7.9, stress leads individuals to restrict attention to a subset of particularly salient cues. However, flexibility leads to more efficient performance under complex conditions in which more than one solution is possible, or in novel task conditions (Driskell et al., 2001). To promote flexible thinking, training material must be presented in a number of different contexts, from different perspectives, and with diverse examples. The practice of a narrow set of skills in training will result in the use of a narrow set of skills in the real world.

In the third phase of training, the participants are given the opportunity to practise the skills through gradual exposure to stress in a training environment. The stressful environment does not necessarily require a high-fidelity simulation. Driskell et al.

(2001) suggest that normal training exercises could be adapted by incorporating stressors such as increased time pressure or noise. Although there are difficulties in creating appropriate levels of stress in such training (Flin, 1996a), the primary outcome associated with the successful completion of the training is improved cognitive and psychomotor performance under stress (Weaver et al., 2001). In a review of 37 articles concerned with stress exposure training, Saunders et al. (1996) found the majority supported the effectiveness of this type of training. Further, there is evidence that skills learned in stress exposure training in a particular type of stressful situation as applied to a particular task, can then be generalised to novel settings (Driskell et al., 2001).

Tertiary prevention

Table 7.11 Core components of CISM (adapted from Everly and Mitchell, 1999)





pre-crisis preparation

Establish expectations. provide information on stress management. develop coping skills.




demobilisation and consultation

inform and discuss.

Allow psychological decompression (e.g. talk about experiences).

Manage preliminary stress.







Reduce acute signs and symptoms.

Begin closure.


Within 12 hours postcrisis

Small groups

Critical incident stress debriefing

facilitate closure.

Mitigate signs and symptoms. refer as required.

Within 1-10 days; 3-4 weeks after a mass disaster

Small groups

Crisis intervention

Return to level of function of before the crisis.

Mitigate signs and symptoms. refer as required.




family critical incident stress management

foster support.

Mitigate signs and symptoms. refer as required.




determine status. ensure closure. refer as required.




Tertiary prevention is concerned with treating team members who have been exposed to an extremely stressful situation. Critical incident stress management (CISM) is an intervention strategy that has been used to prevent pTSD following an unexpected critical event. the goal of CiSM is to restore people to their usual state of mental health by mitigating the effects of traumatic stress. CISM can be applied to individuals, groups or organisations. it can be made available after a particular disaster (e.g. the terrorist attack on the World trade Center; Hammond and Brooks, 2001; the Piper Alpha disaster; Alexander, 1993), or it may be available to emergency service personnel who frequently have to deal with traumatic events (e.g. the Los Angeles County Fire Department has conducted more than 500 CiSMs since its implementation in 1986; Hokanson and Wirth, 2000). a framework for a particular type of CiSM that has been widely used is outlined in table 7.11.

Flannery and Everly (2000) state that with correct training and an effective assessment procedure, then even a limited array of crisis intervention procedures are effective.

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