Principles, Tactics, and Techniques (PTT): How Aviators and Elite Firearms Trainers use PTT to Create Performance Under Pressure

In the ICU, ER, and surgical suite, the requirement to flawlessly perform on demand while under pressure is every bit as high as it is in a fighter jet or airline cockpit or when employing firearms during a mission for the military or law enforcement .

Principles, Tactics & Techniques Drive High Performance Under Pressure

When seconds count and the pressure of the moment can be performance crushing, it’s not just using tactics (e.g., standard procedures or protocols) that save lives and accomplishes the mission—it’s people using those tactics/processes with automaticity because protocols have been ingrained in their neural pathways through rigorous and disciplined daily use.

Performing under pressure comes from the mindset of, "I use standard procedures - even when I don't feel like it - because this is how professionals do their jobs." That's the difference between a "professional" and an "amateur."

Professionals show up every day and do the right thing with discipline and rigor even when it would be easier to skip steps or use workarounds. At the moment of truth during a high stakes event with lives on the line, the amateur performs at the level of their daily work; their performance very rarely ever rises to the occasion. The professional, however, responds with automaticity and reserves their high order thinking for solving unexpected problems—not executing the basics.

Because they’ve practiced the fundamentals with consistency and integrity, their actions under pressure are smooth, confident, and reliable. They don’t have to think about *how* to act—they just do. This disciplined approach frees up cognitive bandwidth to adapt, lead, and make critical decisions when it counts most. In crisis, amateurs improvise; professionals execute.

Principle Over Tactics: What High-Performing Pilots, Marksmen and Surgeons Have in Common

Pilots of high-performance aircraft and elite marksmen live by a deceptively simple hierarchy : Principles → Tactics → Techniques. This is also a framework for how the best-performing healthcare teams operate. Let's examine the hierarchy in more detail.

Principles are "non-negotiable truths" for performing the mission. An example of a patient safety principle is that zero preventable harm is the product of expert clinical knowledge, 200% accountability, creating a sense of psychological safety, effective communication, speaking up when a problem with patient care is perceived, team problem solving, and giving and receiving effective performance feedback.

Tactics are the standard processes, procedures, and protocols used in daily operations. Examples of patient safety tactics include conducting a Time Out, using ISBARRQ for handoffs, giving readbacks on critical information, and using a "stop-theLine" script to speak up when problems with patient care are perceived.

Techniques are how the individual team member executes the Tactics. For example, the specific words or phrases, tonality, and body language Dr. Smith uses during a Time Out briefing to build a sense of psychological safety among the surgical team.

High performing teams never train the Tactics or the Techniques in isolation. When expert teams train on techniques, that training always includes the Principle or Tactic the Technique serves.

Here's a Real-World Example of Ensuring Surgical Safety via the Principle-Tactic-Technique Hierarchy

Imagine a surgical team preparing for a complex cardiovascular procedure.

• Principle: The overarching principle is "Zero preventable harm through deliberate teamwork and communication." Every action the team takes must align with this non-negotiable truth.

  
  

• Tactic: To uphold this principle, the team uses a locally customized version of the World Health Organization (WHO) Surgical Safety Checklist as a standardized process (tactic) before making the first incision. This includes confirming patient identity, procedure details, anticipated critical events, and ensuring all equipment and medications are prepared.

  
  

• Technique: Dr. Adams, the lead surgeon, conducts the Time Out checklist (tactic) using specific techniques that foster psychological safety and clarity:

  • Words: Speaking clearly, slowly, and inviting all team members to voice concerns (“Is there anything we’re missing that could impact patient safety?”).

  • Tonality: Using a calm, attentive voice that signals respect and openness, not rushed or dismissive.

  • Body Language: Making eye contact with each team member instead of reading the checklist mechanically.

    
    

Because the team connects the Technique (how the checklist is conducted) to the Tactic (using the checklist itself), and both are rooted in the Principle (zero preventable harm), the team builds trust, anticipates risks, and sets a tone of vigilance for the operation.

If a discrepancy is caught—say, an allergy that was missed during intake—the open communication climate ensures it's caught before it becomes a catastrophic event. That’s Principle-driven performance at work.

That’s why high-performing teams—from fighter squadrons, to SWAT teams, to trauma bays—train with intentional alignment between what they believe (Principles), what they do (Tactics), and how they do it (Techniques). They know that Technique without Tactics and Tactics without Principle leads to fragile performance under pressure.

When healthcare teams train, debrief, and operate with this hierarchy in mind—Principles drive Tactics, and Tactics drive Techniques—they build a culture where performance is predictable, resilient, and safe. It’s not "cookbook medicine;" it’s about understanding why processes matter and executing them with precision and purpose.

In critical moments, it’s not clever workarounds or heroic improvisation that saves lives.

It’s disciplined professionals, grounded in shared principles, executing with their processes (e.g., tactics) with consistency—even when it’s hard.

That’s the real mark of mastery. And that’s what separates high-reliability healthcare teams from all the rest.