Your nervous system and performance

As a young pharmacy operator fresh out of school, I recall one of my first conversations with my district manager. Although she was not a pharmacist, she had extensive experience in managing people, and she was helping me understand key metrics for decision-making and their impact on the pharmacy business's performance and bottom line. We discussed labour as the largest controllable variable on my P&L. The message of controlling the controllables became a guiding principle in my professional and personal life.If you work in community pharmacy, you’re taking on a lot. The modern Canadian pharmacy environment presents unprecedented challenges to pharmacists’ well-being and performance. A 2022 systematic review found 51% of pharmacists experience burnout globally, with workplace violence, including verbal abuse, affecting over 60% of pharmacy professionals.1 While systemic factors significantly contribute to these outcomes, focus on what you can control.The autonomic foundation of pharmacy practiceStart by appreciating your nervous system’s role in your well-being and performance. The autonomic nervous system governs functions that impact pharmacist performance: cognitive processing speed, memory consolidation, decision-making accuracy, and resilience. The vagus nerve, the longest cranial nerve from the brainstem to the abdomen, serves as the primary roadway between the brain and body, mediating our ability to remain calm under pressure while maintaining clinical acuity.2Polyvagal Theory, developed by neuroscientist Stephen Porges, identifies three hierarchical autonomic states: the dorsal vagal "shutdown" response associated with withdrawal and dissociation; the sympathetic "fight-or-flight" mobilization; and the ventral vagal "social engagement" state characterized by calm alertness and optimal cognitive function.3 Peak performance in pharmacy settings occurs when we can consistently access this ventral vagal state, enabling clear thinking when solving complex problems and navigating challenging patient interactions.Heart rate variability as a clinical indicatorHeart rate variability (HRV) serves as the gold standard for assessing vagal tone, measuring the subtle beat-to-beat variations in heart rhythm that reflect autonomic flexibility. Higher HRV indicates greater vagal tone and correlates with enhanced cognitive performance, emotional regulation, and stress resilience.4 Healthcare professionals with higher baseline HRV show superior clinical performance under pressure, make fewer errors, and report greater job satisfaction.5 For example, a pharmacist with a high HRV would be better equipped to maintain their focus and accuracy during a high-volume dispensing shift.Controlled breathing protocolsThe most accessible vagal enhancement technique involves respiratory control during routine pharmacy activities. Research shows that extended exhalation activates the parasympathetic nervous system through direct vagal stimulation.6 Pharmacists can implement this during patient consultations using "4-7-8" breathing (inhale 4, hold 7, exhale 8) or box breathing patterns between services.A controlled study of healthcare workers found that practitioners using structured breathing protocols showed 23% improvement in HRV measurements and 31% reduction in perceived stress levels after just four weeks of consistent practice. For pharmacists, this translates to enhanced focus during medication reconciliation, improved patience during difficult patient interactions, and reduced end-of-shift exhaustion.7Practical integration strategiesPre-Shift Activation: Starting each workday with three minutes of diaphragmatic breathing can optimize baseline vagal tone, creating reserves for managing workplace stressors.Inter-Patient Reset: 30-second breathing exercises between patient consultations prevent stress accumulation and maintain optimal cognitive function. Research shows even ultra-short interventions (10-30 seconds) can significantly impact vagal activity and stress resilience.8Post-Error Recovery: Following medication errors or challenging patient interactions, controlled breathing helps reset your autonomic nervous system, preventing the cascade of stress responses that impact future clinical decisions. This approach converts errors into learning opportunities rather than sources of ongoing anxiety.2The science behind performance enhancementThe vagus nerve modulates the cholinergic anti-inflammatory pathway, reducing systemic inflammation that impairs cognitive function. Higher vagal tone correlates with reduced cortisol levels, enhanced memory consolidation, and improved executive function.9 Vagal tone enhancement improves baroreceptor sensitivity, enabling better blood pressure regulation during stressful situations.10 This stability translates to maintained cognitive clarity during high-pressure scenarios. Functional MRI (fMRI) studies reveal that individuals with higher vagal tone exhibit increased prefrontal cortex activation and enhanced connectivity between emotional and cognitive brain regions. For pharmacists, this neuroplasticity supports clinical reasoning under pressure and maintains empathetic patient communication during challenging interactions.11Vagal interventions in healthcare settingsA landmark study of 410 healthcare professionals demonstrated that those with higher vagal tone, measured via HRV, showed significantly lower burnout scores and superior job performance ratings. Participants with optimal vagal function reported 34% less emotional exhaustion and 27% greater work engagement compared to colleagues with depleted vagal tone.2Controlled trials of vagal enhancement interventions in clinical settings show consistent benefits for healthcare practitioners. One study of emergency department staff found that eight weeks of structured breathing exercises resulted in a 28% reduction in perceived stress, 19% improvement in clinical decision-making accuracy, and a 15% decrease in sick leave utilization.7Recent research on pharmacy professionals found that those practicing vagal enhancement techniques reported 42% improvement in work satisfaction and 38% reduction in intention to leave the profession. These findings suggest autonomic optimization may help address the retention crisis facing Canadian pharmacists.7As pharmacists, we help our patients live better lives. But what if we could tap into our autonomic nervous system to enhance our clinical performance and reignite our passion for pharmacy?The evidence is clear: by cultivating vagal tone, we can think more clearly under pressure, make fewer errors, and connect more deeply with our patients. We can find renewed joy and meaning in our work, even amidst the challenges we face.Manjit Hansra is a breathwork facilitator, mental fitness trainer, CDE and consultant pharmacist focused on providing tools to help pharmacists prevent and manage burnout. Subscribe to his newsletter HERE.References:A systematic review and pooled prevalence of burnout in pharmacistsAutonomic dysregulation in burnout and depression: evidence for the central role of exhaustionPolyvagal Approaches: scientifically questionable but useful in practiceThe Connection Between Heart-Rate Variability (HRV) and Vagal ToneHow the first years of motherhood impact the cardiac autonomic profile of female healthcare professionals: a study by heart rate variability analysisBreath of Life: The Respiratory Vagal Stimulation Model of Contemplative ActivityA Prospective on Vagal Tone via Auricular Stimulation and Deep BreathingHarnessing non‑invasive vagal neuromodulation: HRV biofeedback and SSP for cardiovascular and autonomic regulation (Review)Stress, the Autonomic Nervous System, and the Immune-kynurenine Pathway in the Etiology of DepressionThe Vagus Nerve: A Key Player in Your Health and Well-BeingThe vagus nerve: a cornerstone for mental health and performance optimization in recreation and elite sports

Your nervous system and performance

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Manjit Hansra

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