- Jamie Riggs (1),
- Melissa McGowan (2),
- Andrew Petrosoniak (3)
- Christopher Hicks (3)
1. Faculty of Medicine, University of Western Ontario, London, ON, Canada 2. Department of Emergency Medicine, St Michael's Hospital, Toronto, ON, Canada 3. Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
Mental practice (MP) is the cognitive rehearsal of a skill without physical movement (1), and has been used by high performers in many fields (2,3). Anyone who has watched the Olympics has seen the world’s top athletes with their eyes closed, mentally practicing their already perfected routine one more time. This fantastic post by Mike Lauria provides an outline of the history, neurological basis, and much of the evidence of MP in medicine.
What relevance does MP have to the donning and doffing of personal protective equipment (PPE) during the COVID-19 pandemic? While we don’t have specific evidence for mental practice and PPE, in this time of limited resources, limited time to practice, and working in new or unfamiliar settings, applying the principles of mental practice from other domains to the donning and doffing of PPE may give you a chance to get the practice you want. In the spirit of marginal gains, any intervention that might improve provider safety while protecting scare resources should be considered. Enter mental practice.
Who should use MP?
Pretty much everyone. There is good evidence that MP is beneficial for skill acquisition (4,5,6) and somewhat less suggesting that it decreases perceptions of stress when performed prior to a stressful task or skill (7,8,9). What is currently unknown is whether MP could be an effective way for established practitioners to maintain their competence on little-used but high stakes procedures (think cricothyrotomy, thoracotomy and the like).
It is not a stretch to suggest that donning and doffing PPE is a high risk procedure, particularly in the midst of a pandemic involving a highly contagious pathogen. For many, it may have been months or years since they have practiced these skills. Couple that unfamiliarity with the complex order in which donning and doffing needs to occur, ever-changing PPE guidelines, and high stress and time pressured environments, and the risk of error seems ever-looming. Physical practice is difficult without consuming scarce PPE resources or gathering for in-person education or simulation sessions, both of which are presently discouraged. MP is a portable, reproducible, and entirely free way to maintain comfort and familiarity with any complex or rare procedure.
Where should you mentally rehearse?
A majority of the work in medicine has used MP sessions in quiet, relaxing environments – a far cry from a busy emergency department. Evidence from sports psychology has shown that increasing the ‘fidelity’ of your MP by even a little bit can improve its effectiveness (10).
So what to do? Start your MP routine in a relaxing environment where you won’t be interrupted. As you gain confidence in your imagery abilities, add small elements of realism. Simply standing up, as you would when donning or doffing, can help improve the fidelity of your practice, which in turn improves memory encoding and retrieval.
How can we use MP for donning and doffing of PPE?
Learn the steps. First, familiarize yourself with the steps for putting on or taking off your PPE that align with your local institutional standards: videos, flow charts, whatever. In order to effectively rehearse the steps in your mind, you first need to know them well.
Reflect. If you have experience with wearing the PPE recommended by your organization, think back to your last time you used it. What did it feel like to put on and take off? Were there things that were particularly difficult? These are the details that make mental practice more powerful. Instead of just remembering a list of steps, do your best to incorporate what you see, feel and think about when performing these tasks.
Practice. If you have a donning and doffing video available, play it again, but this time sit somewhere comfortable, with your eyes closed, and use the audio to guide you through the steps. In your mind imagine yourself performing each step, ‘seeing’ your hands completing each task as though you were watching with your own eyes. Add in those details you identified – feel the strap of your visor tighten around your head, imagine what that new mask must smell like.
Refine. Consider making your practice closer to real life conditions. Stand up, keeping your eyes open, and consider miming the actions you are completing with your hands and arms. Continue to use the audio if need be, or consider using a ‘script’ – you can check out the one we made as an example.
Mental Practice Script
Why bother with all this?
Team and personal safety is a big deal, now more so than ever. Using checklists, donning and doffing observers, and physically practicing PPE are and always will be essential. We hope that using the ‘simulator in your mind’ will allow you to become more comfortable with your PPE process, and perhaps relieve some of the stress involved with a new and unfamiliar process.
Video tutorial on how to use mental practice for donning and doffing PPE
1 Richardson, Mental Imagery. London: Routledge & Kegan Paul; 1969.
2 Bernardi NF, Schories A, Jabusch HC, Colombo B, Altenmüller E. Mental practice in music memorization: An ecological-empirical study. Music Perception: An Interdisciplinary Journal. 2013 Feb 1;30(3):275-90.
3 Weinberg R. Does imagery work? Effects on performance and mental skills. Journal of imagery research in sport and physical activity. 2008 Feb 14;3
4 Arora S, Aggarwal R, Sirimanna P, Moran A, Grantcharov T, Kneebone R, Sevdalis N, Darzi A. Mental practice enhances surgical technical skills: a randomized controlled study. Annals of surgery. 2011 Feb 1;253(2):265-70.
5 Lorello GR, Hicks CM, Ahmed SA, Unger Z, Chandra D, Hayter MA. Mental practice: a simple tool to enhance team-based trauma resuscitation. Canadian Journal of Emergency Medicine. 2016 Mar;18(2):136-42.
6 Sanders CW, Sadoski M, Bramson R, Wiprud R, Van Walsum K. Comparing the effects of physical practice and mental imagery rehearsal on learning basic surgical skills by medical students. American journal of obstetrics and gynecology. 2004 Nov 1;191(5):1811-4.
7 Arora S, Aggarwal R, Moran A, Sirimanna P, Crochet P, Darzi A, Kneebone R, Sevdalis N. Mental practice: effective stress management training for novice surgeons. Journal of the American College of Surgeons. 2011 Feb 1;212(2):225-33.
8 Ignacio J, Dolmans D, Scherpbier A, Rethans JJ, Lopez V, Liaw SY. Development, implementation, and evaluation of a mental rehearsal strategy to improve clinical performance and reduce stress: a mixed methods study. Nurse education today. 2016 Feb 1;37:27-32.
9 Wetzel CM, George A, Hanna GB, Athanasiou T, Black SA, Kneebone RL, Nestel D, Woloshynowych M. Stress management training for surgeons—a randomized, controlled, intervention study. Annals of surgery. 2011 Mar 1;253(3):488-94.
10 Smith D, Wright C, Allsopp A, Westhead H. It's all in the mind: PETTLEP-based imagery and sports performance. Journal of Applied Sport Psychology. 2007 Feb 14;19(1):80-92.