Stress and fear have biological functions that, when neuromodulated, make adaptive otherwise maladaptive responses. While the concept of a defensive cascade supports cognitive understanding and hypothesis testing, approaching this domain by function using an ecological approach brings the pragmatic stance with methods for prevention and intervention. Stress, fear, and threat have distinct functions to, respectively, constrain cognition, induce cognitive focus, and reflexively respond when in danger. We differentiate reference frames between a fixed-point reference frame that distinguishes the event (stimulus) from the person (responder and response) and an experiential reference frame within cascading events. Unrecognized, the characteristics and actions of an HRO bring modulation to the defense cascade, check the effects of stress, interrupt cascading fear reactions, and abridge threat reflexes.

Attempts to climb Mount Everest failed for thirty years until a mountain climbing physiologist joined the efforts. This story demonstrates the value of context, inductive processes, and pragmatism to generate local knowledge and solutions in austere, hazardous environments. In these environments, imperfect information and inaccurate models can kill. This story, viewed from the climbers' experience rather than scientists or leaders, underscores the vitality of engaged individuals overcoming physical, social, and mental adversity to "gain altitude." At the individual level, what high altitude climbers learned can support the neonatologist's efforts for the neonate to "gain life." Three times men had climbed to more than 28,000 feet, unaided by oxygen apparatus, and failed to reach the summit.

Stress has become an organizational characteristic. Organizations work toward stress reduction, seek stress management, increase cognitive capacity, attend to our mindfulness, and refer staff for anger management. The HRO acknowledges that stress, fear, and threat are natural elements of dangerous work. They are integral to and support actions when we do not know how events will resolve. Rather than compartmentalizing stress fear and threat, the HRO harnesses these driving forces to initiate engagement and support the resilience necessary to maintain enactment. For this to occur, we must identify unrecognized stress for its deleterious effects on performance. As we accomplish this, the organization can harness this energy to resolve the original stimuli while achieving an acceptable, if not desirable, end-state. The stress-fear-threat cascade enables us to engage uncertainty and threat, but without neuromodulation, the same cascade can cause more damage than the inciting event.

COVID-19 has changed the social, financial, and political environments for healthcare. Healthcare organizations have abruptly changed operations for a new environment due to pervasive threats to the organization, patients, and healthcare professionals. While the direct, infectious presence of COVID-19 as a threat would seem to cause the greatest stress to the healthcare system, perhaps the absence of the threat may cause more severe and wide-ranging problems. Ecological studies demonstrate a greater decrease in prey populations from the predator’s absence due to an “ecology of fear.” By analogy, organizations share these trait responses and can develop an organizational culture of stress or stress. HRO describes functional traits for effective operations in environments of severe threat.

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