STRESS - CONCEPT, RESPONSES AND COPING

OPITO SCMDOPITO063301 10.11.2006 Page 8 of 31 Anxiety This is experienced by the majority of passengers in an emergency situation and may impair their performance of actions that are novel and difficult HUET training aims to reduce the novelty of the situation. Disorientation In a helicopter this results from a reduction in visibility, in-rushing water and the change in orientation following capsize. This will increase levels of anxiety and may result in a failure to locate an exit. Depersonalisation Witness reports from life-threatening events indicate that the passage of time seems to slow. This is thought to be as a result of people detaching themselves from the actual situation in order to think and respond more effectively. Panic It is thought that true instances of panic amongst passengers in accidents are rare and are usually due to feelings of being confined. Behaviour in accidents that might be regarded as panic can be interpreted as a rapid series of rational responses. Inaction It is thought that between 10 and 25 of people do little or nothing to escape from danger. Evidence from accidents seems to indicate that there are many more instances of behavioural inaction than panic. Inaction or freezing is of great concern in the helicopter emergency situation. This may add to the anxiety of an individual who is not seated next to an exit, facing the prospect that the person seated next to the exit will not make a rapid escape and will effectively block the exit. Leach 2004 suggested that freezing could be accounted for by time constraints on the cognitive processing of information in a rapidly unfolding, real-time environment. The main aims of training must therefore be to reduce the likelihood of these behaviours. This can be achieved through familiarisation with likely scenarios, familiarisation with the equipment that might be used and the procedures that must be followed, thereby generating confidence, coping skills and a positive outcome expectancy. 4.2 EFFECTS OF PSYCHOLOGICAL AND PHYSIOLOGICAL STRESS ON PERFORMANCE Performance in a threatening situation will depend upon the level of perceived threat, the coping abilities of the individual and the resultant level of stress experienced. It has been reported that lack of control over a stress condition can result in higher levels of reported helplessness, tension, anxiety and physiological activation of the HPA axis Breier et al, 1987. Whilst low levels of anxiety can be experienced without any significant decrement in performance see Idzikowski Baddeley, 1983 there is a large amount of literature showing that higher levels of stress result in cortisol release that is known to affect cognitive function. Much of the focus on the effects of stress on performance has thus focussed on the effects of cortisol on the body and its role in the stress response. Cortisol is known to be produced in response to both psychological and physiological stressors, although there is a wide variability in cortisol response between individuals. Cortisol levels have been linked both to defence and to coping see Harris, 1995 for review. It is also known that glucocorticoids such as cortisol, secreted in response to stress, have an affect on cognitive performance by impairing declarative memory recall, defined as the conscious recollection of learned material Elzinga et al, 2005; Kirschbaum et al, OPITO SCMDOPITO063301 10.11.2006 Page 9 of 31 1996; Sauro et al, 2003. Anticipation of a stressful event has been shown to play a more significant role than the actual stressor in impairing declarative memory Lupien et al, 1997. However, whilst declarative memory was impaired, the study by Kirschbaum et al 1996 showed no impairment in a procedural memory task. This suggests that those experiencing stress and anxiety may find it more difficult to remember instructions during the training, but the process of learning the physical actions or tasks required to complete the escape exercises may not be affected by stress. In a study of the effects of acute stress on immune and cognitive performance during emergency response training, Robinson 2005 found no changes in short-term working memory but did show some impairment of declarative memory in the period prior to HUET training. Robinson cites several reports of survival experiences where individuals have failed to carry out life-saving behaviours requiring procedural memory. She found some impairment in working and procedural memory during the impact stage of training, whilst poor decision-making was observed during the recovery phase. Caution should be taken in interpreting the effect on procedural memory as the test used was a word task and did not involve a physical task. Her overall conclusion was that cognitive performance is very robust and dysfunctions were, on the whole, difficult to elicit Robinson, 2005; p227. She considered that the impact stage HUET exercises was the part of the threatening situation when the individual was most susceptible to cognitive impairment. Thus, anything that can be done to reduce the perception of threat during the HUET exercises should help to improve procedural memory, learning and hopefully, retention of that learning. 4.3 STUDIES OF STRESS DURING OFFSHORE EMERGENCY RESPONSE TRAINING An early study of HUET training of US navy personnel using a prototype breathing device showed a decrease in anxiety over the course of three days of training Ryack et al, 1986, leading to a recommendation in support of HUET training for all crew members. The first major study of the psychological and physiological effects of helicopter underwater escape training was conducted by Hytten et al 1989 in Norway. Overall, most of the 78 trainees developed a positive response outcome expectancy and increased confidence in flying. Anxiety levels were low in those with earlier similar experience. Higher levels of anxiety were found in those who perceived the ditching as more demanding than expected. The authors considered that high anxiety levels prevent the development of a positive response outcome expectancy by interfering with the cognitive functions needed during training. A more individualised approach to training was recommended. Work in Canada looked at the potential benefits of using an emergency breathing system EBS to aid underwater escape Bohemier, Chandler Gill; 1990. They found that use of EBS was beneficial in helping subjects to deal with more difficult seat positions cross- cabin escapes and resulted in an improved probability of making a successful escape over a sequence of 7 exercises. Both with and without EBS, subjects showed an increasing ability to cope with disorientation as experience in the simulator was gained. A comprehensive study of stress during all aspects of offshore survival training, conducted from 1991 to 1994 1 , Harris, Coleshaw MacKenzie 1996 found the highest levels of anxiety at the time of enrolment onto the course and prior to HUET training. Pre-course 1 Five day combined basic course; three day refresher further course. OPITO SCMDOPITO063301 10.11.2006 Page 10 of 31 anticipatory anxiety was associated with an increase in urinary and saliva cortisol levels, suggesting arousal of the nervous system. Anxiety levels, both early morning and pre- event, when placed in chronological order, decreased over the duration of the course, suggesting a degree of habituation with time as individuals learned to cope with the experience. The mean state anxiety score for combined trainees prior to HUET training 42.3±12.0 was similar to the mean score for college students under examination conditions 43.0 - males; 43.7 - females reported by Spielberger et al 1970. Both mean state anxiety scores and heart rates were higher in the combined group compared to the refresher group prior to HUET training Harris, Coleshaw MacKenzie, 1996. State anxiety was also found to be higher in young compared to older trainees in the refresher group, but this negative correlation with age was not found in the combined group who were mostly attending a course for the first time. Both of these findings may be explained by a greater level of apprehension and anticipatory anxiety in those attending their first training course, whilst the older, more experienced individuals who had attended training on multiple occasions knew what to expect and had developed coping strategies. Not surprisingly, non-swimmers were more anxious than swimmers. Smokers tended to experience higher levels of state anxiety and coped less well than non-smokers, whilst anxiety was also higher in those who rated themselves less fit. These latter two factors are important, as physical inactivity and smoking are both coronary risk factors. A later study by Muir and Mills 1999, commissioned by Shell, which aimed to develop a training standard for underwater survival, found that higher fidelity training including operation of emergency exits caused more stress. However, they supported the need for part-task learning whereby trainees skills are built up in an incremental fashion. Trainees performance and confidence were both improved as a result of conducting two inversions. Many experienced severe disorientation in the first inversion and learnt more during a second inversion when they knew what to expect. Those who had experienced the higher fidelity training were more confident as a result of their training. Levels of stress measured during a test inversion were lower in those who had completed an inversion during training than in those who had not completed an inversion during training. The authors also supported comprehensive classroom and practical training in the use of EBS. They found that participants were able to remain in the helicopter simulator for longer periods and stated that the increased window of opportunity for escape due to use of the air-pocket helped reduce feelings of panic. A recent study of the cognitive and neuroimmune responses to the pre-impact, impact, recoil, rescue and post-trauma stages of survival training Robinson 2005 showed some cognitive impairment during the impact and recovery phases of HUET training see also Section 4.2. This suggests that high levels of stress could have an effect on training outcomes and the ability of delegates to learn and retain information relating to escape procedures, a factor that should be considered when assessing the impact of the proposed changes. 4.4 STRESS IN OTHER THREATENING SITUATIONS Studies of stress in threatening situations are limited by the difficulties of obtaining controlled data. Those studies that have been conducted use a wide variety of physiological and psychological measures making comparisons and estimates of the level OPITO SCMDOPITO063301 10.11.2006 Page 11 of 31 of stress experienced in other similar situations very difficult. Studies that have been conducted tend to fall into a number of areas: • Emergency response training e.g. fire-fighters; • Military personnel undergoing training; • Potentially dangerous sports such as parachuting; • Everyday phobias such as fear of driving. Fire-fighting requires personnel to perform under conditions of severe short-term stress. They are exposed to both physiological and psychological stressors. Heart rates up to 86 of maximum, over 150 beats per min Kivimaki Luse, 1994, and elevated cortisol levels Smith et al, 2005 have been recorded during fire-fighting drills. Impairment in cognitive functioning has been demonstrated by reduced task-focussed thinking intentional thinking aloud during solitary smoke diving Kivimaki Luse, 1994. In a study of stress and coping in the follow-up to a hotel fire rescue, 10 of the relatively inexperienced non-professional fire-fighters present claimed that stress reactions disturbed them in executing effective rescue work Hytten Hasle, 1989. The majority considered that more training and preparation could have improved their effort. The professional fire-fighters involved were said to have digested the disaster experience more easily, coping better with the extreme stress of the situation. Idzikowski and Baddeley 1983 reviewed a number of studies of military and sports parachuting and showed increased activation of heart rate, respiration, hormone secretions e.g. adrenaline and blood glucose levels preceding and during the jumps. Levels of anxiety increased as the time of the jump drew closer, with novices showing the greatest physiological arousal at the time of exit from the aircraft. In one study, experienced sports parachutists showed a moderate increase in arousal before entering the aircraft, put down to excitement and anticipation of the forthcoming jump. This finding must be tempered by the fact that there is a high drop-out rate from the sport of parachuting after the first jump and it follows that experienced parachutists are those who are not frightened by the experience but enjoy the low levels of apprehension experienced. Experienced parachutists are thus a self-selected group who appear capable of coping with any anxiety experienced. When an element of uncertainty was added into an experienced parachutists jumps by telling him that his [main] parachute might fail on a number of occasions due to incorrect packing his responses regressed towards those of a novice jumper see Idzikowski and Baddeley, 1983. It was also noticed that those parachutists who adapted well did not deny their fear. A more recent study of military parachutist trainees showed a deterioration in performance of cognitive and psychomotor tests prior to the tower and aircraft jumps, which correlated with the level of anxiety experienced Sharma et al, 1994. They referred to an internal fear in paratroopers even when they are fully trained and experienced. This was considered to be due to a lack of control over events and the fact that the real threat of military operations remained. This military situation is thus different to the HUET training situation where the real threat of a helicopter accident during the working life of an offshore worker is extremely low. Studies in divers suggest that the greater the perceived danger of a dive due to increasing depth, the greater the impairment of performance of manual dexterity tests Idzikowski and Baddeley, 1983; Mears and Cleary, 1980. This decrement in performance correlated with an increase in self-reported anxiety. The effect could not be explained by depth per se as tests in a land-based pressure chamber showed only a small impairment due to depth. It was concluded that heightened anxiety was the most likely explanation for the marked performance decrement observed in novice divers during an open sea dive and that this was associated with perceived risk see Mears and Cleary, 1980. Diving under OPITO SCMDOPITO063301 10.11.2006 Page 12 of 31 excellent, clear and calm water conditions showed the least decrement in performance, considered to be due to a less anxiety-provoking environment see Idzikowski and Baddeley, 1983. SCUBA diving is considered to be a high-risk sport, with a consensus view that many injuries and fatalities are caused by panic Morgan, 1995. However, it has been shown that levels of anxiety in this type of environment can be reduced by giving trainees a realistic expectancy of what might be experienced underwater, training them in how to cope with the environment and their own negative thoughts. Training is considered to be paramount in limiting the damage and injuries incurred in many diving accidents. A study of individuals with a situational phobia about driving showed higher state anxiety and secreted more cortisol, not only during the actual exposure but also in anticipation of the exposure Alpers et al, 2003. Whereas the anxiety ratings habituated with time over 3 driving sessions, there was little habituation of the cortisol response. These authors suggest that a lack of control over the stressor may have contributed to the physiological activation. This lack of control is similar to the situation found during HUET training. Trainees have a limited level of control over the helicopter simulator exercises, often having to follow set procedures within a group training session. Driving is a multiple task activity where the driver must be able to operate the vehicle whilst also concentrating on other vehicles, pedestrians, signs etc. With dualmultiple task activities there is evidence that secondary task performance may deteriorate in frightening situations. One of the reasons for this may be a narrowing of attention due to elevated arousal levels. As a result, the individual may show a tendency to miss peripheral stimuli. This also has parallels with HUET training where the individual must concentrate on the operation of equipment e.g. EBS and harness whilst also focussing on the escape route. Phobic anxiety is commonly reported in association with commercial flying, both in passengers but also in some aircrew members Medialdea Tejada, 2005. An anticipatory state anxiety and an inability to relax despite adequate explanations of the true situation were described. Those with a fear of flying often recognised that their fears were unreasonable. In aircrew members, flying phobia was associated with a history of prior aircraft accidents, stressful life events, depression and other mental disorders Medialdea Tejada, 2005. Treatment techniques included desensitisation, relaxation training, and in some cases, treatment of the psychiatric disorder. The study of aircrew members Medialdea Tejada, 2005 also showed that some individuals will continue in a profession despite experiencing anxiety if the rewards are sufficient to justify this. It might have been predicted that self-selection would have caused pilots suffering from anxiety to leave the profession. Self-selection has been demonstrated in air-traffic controllers Collins et al, 1991. A group of 1,790 air-traffic controllers reported significantly lower state current and trait proneness levels of anxiety than did either college students or military recruits. The low anxiety characteristic was also related to job success during field training. In Idzikowski and Baddeleys 1983 summing up on the fear of dangerous and threatening environments they concluded: the magnitude of any response will depend on a number of factors: a the individuals predisposition towards feeling anxious trait anxiety and being aroused trait-arousal; b the individuals assessment of the dangerousness of the situation and his [her] ability to cope with it; c previous exposure. OPITO SCMDOPITO063301 10.11.2006 Page 13 of 31

4.5 IMPACT OF STRESS ON HEALTH STATUS

As described earlier, stress generally means the mental and physical response of the body to demands placed upon it. There is an optimal level of arousal that means that a little stress will help the body to react to a challenge or threat, whereas an excessive response to a stressor can have negative effects. When considering the health impact of stress, the main concern for most people, and the concern with the greatest potential impact is the risk of coronary heart disease. There are now known to be many coronary risk factors. Action can be taken by the individual to reduce some of the major factors that include smoking, high blood pressure, high blood cholesterol and physical inactivity. The main risk factors particularly associated with sudden cardiac death are reported to be an elevated resting heart rate ≥ 90 beatsmin, heavy drinking and arrhythmiairregular heart beat Shaper et al, 1993; Wannamethee et al, 1995. Most of the literature considering the effects of stress on coronary health focuses on chronic psychosocial stressors such as work control, personal relationships and life events such as bereavement. Effects of anxiety on the risk of coronary heart disease have concentrated on trait anxiety, referring to how prone an individual may be to anxiety and differences between people in their background tendency to respond to perceived threatening situations. A number of large prospective studies have shown an association between chronic anxiety and fatal coronary heart disease, in particular, sudden cardiac death Haines et al, 1987; Kawachi et al, 1994; Albert et al, 2005. There are a number of possible causes. It has been suggested that acute stress, such as bereavement, may trigger irregular heart rhythms and myocardial ischaemia restricted blood flow to the tissues of the heart Rozanski et al, 1999. Rozanski et al 1999 recognised that psychosocial stresses tend to cluster together and when they do so, the resultant risk for cardiac events is often substantially elevated. These authors also commented on the impact of sudden stressors e.g. a high work-load exercise test without warm-up compared to graded stressors e.g. graded exercise test with increasing work-loads. It is significant that the severity of cardiac events found in the graded stressor was much less than that found with the sudden stressor. It can therefore be supposed that graded training will benefit the health of trainees. It has also been recognised that psychological factors usually have no acute deleterious effects in the normal heart, whereas in the diseased heart, the consequences may be hazardous Hartel, 1987. In many cases of sudden death, there was a history of previous myocardial infarction or known cardiovascular disease Greene et al, 1972. A lower level of risk was proposed by Bunker et al 2003. An Expert Working Group of the National Heart Foundation of Australia undertook a systematic review of the evidence relating to major psychosocial risk factors to determine whether there were any independent associations between any of the risk factors and the development or progression of coronary heart disease or the occurrence of acute cardiac events. The group fond no strong or consistent evidence for a causal association between chronic life events, work-related stressors job control, demands and strain, Type A behaviour patterns, hostility, anxiety disorders or panic disorders and coronary heart disease. They compared the increased risk contributed by these factors as being of similar order to factors such as smoking and hypertension. Whatever the true level of risk, it should be recognised that psychosocial support, regular exercise, stress reduction training, a sense of humour and optimism have all been cited as means of reducing the risks of stress on cardiovascular health Das OKeefe, 2006. OPITO SCMDOPITO063301 10.11.2006 Page 14 of 31 When considering the potential for sudden cardiac deaths during training, anecdotal evidence suggests that risks are very low. Fifteen years ago Doig and Horsley 1991 reported 3 deaths over a 5-year period that led to the introduction of medical screening for course delegates. Since 1991, medical screening has become the norm. OPITO guidance relating to BOSIET and FOET training recognises that the training contains physically demanding and stressful elements. It is therefore now an OPITO requirement that trainees either possess a valid, current UKOOA medical certificate or undergo an appropriate medical screening prior to commencing training OPITO, 2003. Employment offshore is dependent upon a medical examination conducted on a 3-yearly basis for personnel aged up to 39 years, every 2 years for those aged to 40-50 years and annually for those over 51 years this is due to change in January 2007 to a 2-yearly UKOOA medical for all, irrespective of age. The UKOOA medical guidelines state that the cardiovascular system should be free from acute or chronic disease and that hypertension is acceptable provided it is uncomplicated and well controlled by treatment . This should screen out some individuals with known cardiovascular disease who may be at higher risk. The author is only aware of two fatalities including one in the UK since 1991 where offshore emergency response training may have contributed to the cause. This is despite training numbers of tens of thousands per year in the UK alone. It is also interesting to note that heart rate responses measured during HUET training have been shown to be lower than those measured during other events during emergency response training, some of which are more physically demanding Harris, Coleshaw MacKenzie, 1996. Consultation with a number of UKOOA registered occupational physicians identified a number of issues. Stressors discussed included both the potential threat experienced by some individuals, but also the fear that job security depended upon successful completion of the course. The personal view of one medical officer was that emergency response training is much less stressful now than it had been 10 to 15 years ago, related to continuous changes and improvements to the training and the way it was delivered e.g. less machismo attitudes. A strategy of minimising stress where possible was supported. Whilst previous research has demonstrated that individuals exposed to a stressful event can have an increased risk of illness due to a suppression of immune function, Robinson 2005, p228 found no evidence that exposure to the threat of survival training could result in immuno-suppression. 4.6 EFFECTS OF AGE The increasing average age of the offshore workforce has been a concern for a number of years. A recent survey conducted by RGU in association with the OCA and COGENT showed a small number of people aged over 65 years still working offshore, and a significant number aged 55 to 64 years old 1,000 people in this survey see Energy International, Jan 2006. It is generally considered that the older members of the offshore workforce are a self-selected group of experienced personnel. Such individuals are likely to have completed emergency response training on a repeated basis. It can be supposed that most of this group will have developed coping skills with regard to any anxieties they may have regarding the training. Some concern remains regarding any new recruits to the industry in the older age groups who may not have developed coping skills. An inverse relationship between age of the individual and levels of anxiety in refresher further course delegates was found in the 1994 study of stress in survival course trainees Harris, Coleshaw MacKenzie, 1996, i.e. younger individuals were more anxious than their older peers. No effect of age was found for combined basic course delegates. This suggested that the refresher course delegates had gained benefit from