Peak Performance Under Pressure by Dr Stephen Hearns
Reviewed by Dan Spiers
In June 2020 the British Army’s Centre of Army Leadership published Leading Through Crisis: A Practitioner’s Guide. It was written after the Centre provided mentors and leadership advice to the NHS and local government during the peak of the COVID-19 crisis. Peak Performance Under Pressure: Lessons from a Helicopter Rescue Doctor may have been published in 2019 but it could be argued that is the medical profession’s gift back to the military, as well as the other emergency services.
Peak Performance Under Pressure introduces the ‘Owning the Pressure’ model, based on the authors experience of remote medicine. The model helps teams maintain high level performance in high-pressure environments, the kind that might be found when stabilizing severely injured patients in remote locations, hampered by poor weather. The model can easily be applied by military and other emergency service professionals in high pressure environments such as casualty evacuation, public order and firearms incidents or complex rescues following road collisions.
The author, Dr Stephen Hearns, is a consultant in emergency medicine and leading member of Scotland’s EMRS – the Emergency Medical Retrieval Service. The EMRS, created in 2004, provides pre-hospital care in remote and austere locations. Dr Hearns has also been a member of the Arrochar Mountain Rescue Team for 20 years, has provided medical support to expeditions in challenging environments worldwide, as well as visiting sister retrieval services all over the world to learn and develop techniques for extreme emergency medicine.
As a result he is current, competent, credible and connected. These are important credentials to professionals who place high value on being taught by people with authentic experiences that reinforce their teaching.
Owning the Pressure
Hearn’s ‘Owning the Pressure Model’ is made up of four components: The Pressure Pump, Pressure Control, Pressure Testing and Pressure Relief. Each are explored in four separate sections within the book. These sections are preceded by an opening section called Under Pressure which acts as an executive summary for the book and the ‘Owning the Pressure’ model
Section One – Under Pressure is divided into three chapters. The first chapter titled Flow Frazzle and Owning the Pressure opens with a plane crash at Surrey’s Blackbushe Airport in 2015. The reader is introduced to the concepts of cognitive overload (the inability to process information effectively), cognitive appraisal (the perception of situation, risk and the ability to overcome) and the resulting stress response. It then explains the Yerkes-Dodson law which describes how performance can increase with pressure but only up to a certain point (Yerkes and Dodson 1908).
Dr Hearns then explains how absence of pressure can cause ‘Disengagement’ but as pressure increases an individual or team can enter an optimal phase of ‘Flow’ where performance is at its highest. However, as the pressure continues to increase a state of ‘Frazzle’ can be entered where performance then decreases.
Thinking Under Pressure explains how the brain receives and processes information using short-term and long-term memory and the differences between Implicit long-term and explicit long-term memory. Dr Hearns references Daniel Kahneman’s book Thinking Fast and Slow to explain how analytical memory (slow) and automatic memory (fast) are used by a practitioner to make decisions whilst under stress. The chapter also busts the myth around multi-tasking and explains why multi-taskers are actually very rare.
Back Pressure – Barriers to High Performance discusses how cognitive bias, the Dunning-Kruger effect (over confidence in inexperienced practitioners), fatigue, interruptions; and the environment can challenge optimum peak performance.
This opening chapter is extremely important in setting out the necessity of the ‘Own the Pressure’ Model. Dr Hearns communicates with the reader in a style akin to how he might speak to the relatives of a patient. Setting out the subject matter in a digestible format and helps the reader to fully understand how and why the pilot of the aircraft that crashed at Blackbushe became cognitively overloaded and unable to see that his initial plan to land safely was fatally flawed.
The Pressure Pump
Section Two – The Pressure Pump stresses the need for individuals and teams to be well supported by their organization that has a strong culture and ethos and which maintains an appropriate level of pressure to ensure performance flow. Cultures of excellence explores how psychologically safe organisations like the Royal Marines and the Sky Cycling Team use rigorous selection, standards, competencies and continuous performance monitoring to maintain high standards of performance.
Strategic Leadership of High Performance Organisations calls for leaders to create an open and empowering environment which allows its people to make high risk decisions. The value of coaching and maintaining high levels of motivation is also emphasized. Finally Selecting High Performers looks at how the RAF’s Officer and Aircrew Selection Centre have developed a near perfect process of identifying potential aircrew. The list of qualities required for a person to operate under high levels of stress (including emotional intelligence, resilience and a sense of humour) will be familiar to military and emergency service personnel.
Section Three – Pressure Control is at the heart of Peak Performance Under Pressure and promotes the use of cognitive aides. Having previously established that long term explicit memory recall decreases under stress, Guidelines and Accessing Information under Pressure and A Check List for Checklists promote the importance of quality guidelines and checklists to assist individuals and teams operate at peak flow during stressful incidents.
The High Performing Team explains how structured communication, situational awareness and cooperative behaviour empowers teams to achieve peak flow. It promotes graded assertiveness which empowers junior members of a team to raise issues. Quality leaders are encouraged to use ‘Rally Points’ whereby the perspectives of the team are sort to ensure maximum situational awareness and a shared mental model. Frontline Leadership lists the qualities of a leader and applies high value to emotional intelligence and leader vulnerability.
These sections have a strong resonance with the Centre for Army Leadership’s Leading Through Crisis: A Practitioner’s Guide where Army leaders are asked to communicate honestly and encourage challenge. Tools of the Trade explores the need for high performance teams to be matched with the right equipment and be proficient in operating such equipment.
Section Four – Pressure Testing states the importance of organizational training to deal with pressure situations and the recognition of Frazzle. Training for High Performance expresses the need for quality training that sets out clearly defined qualities. Referring to Section One the book emphasises the need for constant drilling of techniques to embed them into the implicit memory which allows tasks to be carried out quickly and subconsciously. This will be familiar to members of the military are trained to carry out tasks such as weapon handling but is perhaps lacking in the policing world (the lack of regular officer safety training an example).
Simulation and Competency Assessment calls for the use of realistic simulation and constructive feedback to prepare teams for incidents of high stress; and Personal Preparation for High Performance encourages mental rehearsal, task visualization and physical fitness.
Section Five – Pressure Relief Valves deals with how individuals and teams can recover if they slip into Frazzle. Techniques discussed include controlled breathing, cognitive reframing, visualisation and mantras. The art of delegation, articulation of your feelings to team members and the use of cognitive aids are included.
Finally, Section Six – Owning the Pressure – The EMRS Experience provides the reader with two scenarios involving Dr Hearns one from 1998 six years prior to the formation of EMRS and one from 2017 which occurs 13 years after EMRS’s creation.
The differences highlighted in the two stories vividly articulate the merits of the whole ‘Owning the Pressure’ Model proposed by Dr Hearns and acts as a final summary encompassing all the elements therein. It also action as an inspiration for what can be achieved when the various stages of the process come together.
Owning the Pressure
Dr Hearns’s work can be compared to Matthew Syed’s Bounce, an insight into how those in Sports and the Arts achieve greatness. However, the unique selling point for Peak Performance is that it is perhaps a more realistic guide to how individuals or teams can achieve consistent high performance. Within the Leadership genre the book sits comfortably next to Chris Fussell’s One Mission: How leaders build a team of teams, which is aimed at mid-level/strategic leaders.
However Peak Performance is primarily directed at the leaders and members of small teams – perhaps platoon and below – while nodding to middle management in regard to training and employee welfare and organizational culture and ethos – subjects that will interest those at the sub-unit level and above.
It could be argued that Peak Performance is closer to James Kerr’s Legacy which combines performance and leadership within its pages. Once again, and like Bounce, Legacy can feel slightly out of reach as it charts the story of a world-renowned brand, whose players are uniquely wrapped in all the trappings of elite sport. Peak Performance offers a more realistic and obtainable outcome to front line staff.
Peak Performance Under Pressure is an excellent book because it practices what it preaches. The book is written in an easy to digest style and communicates simply and effectively with the reader. It provides checklists at the end of each chapter which act as a cognitive aide.
The mantras ‘Owning the Pressure’ and ‘Achieving a Shared Mental Model’ are repeated throughout the text and in doing so maintain the reader’s focus. By giving the reader permission to own their cognitive capacity (or lack thereof) and promoting a culture of the flat hierarchy the book aligns with the British Army’s modern thinking around empowerment.