Professionalism and performance

PERFORM – Novel research in health performance optimisation

Helen Church


In what feels like many moons ago, in 2021, I virtually attended the International Physicians Health Conference. There I heard Dr Helen Church, from the University of Sheffield, talk about her research with the snappy title, The PERFORM PhD Project. 

Her research investigates whether performance related interventions could work for a real set of doctors working in the NHS to improve patient care and wellbeing of the care provider. 

So, across our time zones, and when Helen was about to have her baby (!), we ‘sat’ down and discussed her research.  And recently, we caught up again to finish this piece…. 

  1. Dr Church, can you tell us what a Performance Enhancing Routine (PER) is?

A Performance Enhancing Routine (PER) is based upon the sport psychology Pre-Performance Routine, which is a behaviour or action undertaken by a sporting professional or elite athlete immediately prior to a skill, for example goal-kick, teeing off in golf or the beginning of a race. A pre-performance routine can be a physical act such as bouncing the ball a certain number of times before serving in tennis, or it can be more of a psychological skill such as visualising where the tennis ball may land on the court.

It’s probably fair to say that most people who have watched any sporting competition or match have noticed athletes and sports people perform these routines or “rituals” but perhaps haven’t always realised why they were doing it. Essentially, it’s about getting in the zone and not letting negative behaviours or emotions, such as nerves or the pressure of a high-stakes competition, affect sporting performance.

Medical school teaches you lots of skills, like history taking, examination skills and procedural skills. But doesn’t always account for the complexities of the clinical environment that affect performance. As a junior doctor I often felt that I had the knowledge and skills to do the job. However, often I felt unable to apply these optimally because I was distracted by feeling scared or anxious in the moment, especially when taking care of the acutely unwell. I found it interesting that athletes were taught how to use routines to prepare themselves mentally for stressful situations, and yet clinical medicine, arguably one of the most pressured and high-stakes jobs that you can do, didn’t incorporate any similar training. 

My PhD project was based on this gap that myself and my supervisors identified in this area, essentially borrowing techniques from sport psychology to see if they could benefit clinicians and their patients in the real clinical setting. However, we wanted to extend the use of a Pre-Performance Routine to one that could be used at any point throughout a task, not just immediately before a task. 

Therefore, the phrase Performance Enhancing Routine (PER) was used, which indicates that the routine can be performed at any time before or during a task, or even afterwards!

  • From your research, can a PER improve our patient care and our performance in general in our jobs in health care? 

Yes it did. My research, although only including a small number of participants due to it being a single-researcher project, demonstrated that the doctors who used PERs reported that they had improved control over any negative behaviours and emotions during stressful situations. This in turn enabled them to deliver better patient care in a timelier manner. Their team-working skills with other healthcare professionals also improved through calmer and more decisive communication skills. 

I think it’s important to point out that the doctors who used PERs didn’t suddenly lose the feelings of anxiety, under-confidence or nerves during these patient encounters. They were however able to better control the effects of these negative emotions so that they did not interfere as much with their clinical performance. 

  • So, it seems this could be a really positive, efficient intervention for many who work on the front line. But it can feel like there might be no ‘extra time’ to fit in a PER in the care of the critically unwell. What are some PER that could work in the busy clinical setting?  And if you try one PER and it doesn’t ‘work’, could a different one ‘work’ as an alternative?  

This is a really good point about having time to apply a PER in a clinical emergency. Often the participants would use a PER prior to a clinical situation, such as a cardiac arrest call, as they were walking or running to the patient’s location. This is a really effective use of time. Something I personally did a lot when I was training to be an anaesthetist, such as using a trigger word in my head, like ‘airway’ to remind myself of the difficulty airway management protocol.

Taking deep breaths is another sport psychology-based PER which can be done quickly and undertaken en-route to the patient, or even just taking one single long breath over a couple of seconds in the middle of a clinical procedure, such as inserting a central line, can make all of the difference to your success rate.

For my PhD we not only considered the use of the Self-Regulated Learning cycle as a reference for when you might want to use a PER during a clinical task (I.e., before, during or after a task), but we also contextualised the use of the routines within a model of metacognition. In brief, metacognition is defined as ‘thinking about thinking’, but I like to consider it as that gut-feeling or non-specific reaction when you know you’ve missed something or you feel uncomfortable, but perhaps can’t always articulate why you feel that way. 

We named it the PERFORM (Performance Enhancing Routines For Optimisation of Readiness using Metacognition) model, and it is generic so can be used in both clinical or non-clinical situations. It offers a really simple way to guide an individual to select, apply and evaluate the use of a PER in any situation and was demonstrated by the junior doctor participants in the PERFORM research project that it is applicable and personalisable, through the adaptation and invention of PERs, during clinical emergencies and other scenarios in and outside of work.

  • If there are medical or nursing educators reading this and want to know more, could you let us know of your recommended reading in this area?  

Yes of course. There are three key papers published from the output of this work. Firstly, a personal opinion piece which draws parallels between sport and medicine and sets the tone for the use of PERs to optimise clinical performance. (1)

Secondly, the AMEE guide number 121, which includes a detailed and comprehensive explanation of the theory underpinning the PERFORM model and examples of how it might be used in real life. (2)

Finally, our latest publication is the main data output from the PERFORM study, which demonstrates how the use of PERs improved doctor’s control over negative emotions and behaviours, the effect on their team-working skills with other healthcare professionals and how these both optimised clinical performance. This paper gives a real-life context to the application of the PERFORM model which is hopefully really useful to anyone considering using it. (3)

Of course, I should mention that the PhD thesis is also available on request should anyone be that keen!! (4)

  1. Helen Church, Deborah Murdoch-Eaton, Rakesh Patel & John Sandars (2017) What can medical educators learn from the Rio 2016 Olympic Games?, Medical Teacher,39:6, 665-666, DOI: 10.1080/0142159X.2016.1270440
  1. Helen R. Church, James L. Rumbold & John Sandars (2017) Applying sport psychology to improve clinical performance, Medical Teacher, 39:12, 1205-1213,DOI: 10.1080/0142159X.2017.1359523
  2. Church, Helen R. MBChB, PhD; Murdoch-Eaton, Deborah MBBS, MD; Sandars, John MBChB, MSc, MD Using Insights From Sports Psychology to Improve Recently Qualified Doctors’ Self-Efficacy While Managing Acutely Unwell Patients, Academic Medicine: May 2021 – Volume 96 – Issue 5 – p 695-700 doi: 10.1097/ACM.0000000000003809
  3. Church, Helen (2019) PERFORM: Performance Enhancing Routines for Optimising Readiness using Metacognition For the Management of Acutely Unwell Patients.PhD thesis, University of Sheffield.

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