NATO Chief Scientist Report - Special Ops

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Advancing the NATO Special Operations Forces Lifecycle

NATO Science and Technology Organization (STO) Review Report NATO Chief Scientist Research Report This document should be announced and supplied only to NATO, Government Agencies of NATO Nations and their bona fide contractors , and to other recipients approved by the STO National Coordinators.

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Volume 4 July 2022

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DISCLAIMER The research and analysis underlying this report and its conclusions were conducted by the NATO Science & Technology Organization (STO). This report does not represent the official opinion or position of NATO or individual governments.

This report has been optimised for reading digitally, including internal and external links.

NATO Chief Scientist Research Report

E. J. Braithwaite L. G. Lim D.F. Reding A. De Lucia

NATO Science & Technology Organization Office of the Chief Scientist NATO Headquarters B-1110 Brussels Belgium http:\www.sto.nato.int

NATO Chief Scientist Research Reports provide evidence‑based advice or policy insights based on research and analysis activities conducted across the NATO Science & Technology Organization.

Activity findings relevant to this Report are already published or will be published on the NATO Science & Technology Organization website: <http:\www.sto.nato.int>.

This report is distributed free of charge for informational purposes. The sale and reproduction of this report for commercial purposes is prohibited. Extracts may be used for bona fide educational and informational purposes subject to attribution to the NATO Science & Technology Organization.

For graphics used from DVIDS, please note: The appearance of U.S. Department of Defense (DoD) visual information does not imply or constitute DoD endorsement.

Copyright © NATO Science & Technology Organization, 2022.

First published, July 2022.

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EXECUTIVE SUMMARY

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EXECUTIVE SUMMARY This report addresses, for a broad audience, the body of NATO Science and Technology Organization (STO) research, conducted between 2012 and 2022, relevant to human factors issues for the future of Special Operation Forces (SOFs).

The aim is to provide the Alliance’s Special Forces community with relevant human factors insights, highlight opportunities to support developments within NATO Special Operations Headquarters (NSHQ), and bring to light opportunities for future collaboration with the STO. The report is centred on the three phases of the operator’s lifecycle: • Phase One: Identify, Prepare, Assess

Phase Two: Select and Train Comprehensive training programmes enhance operator effectiveness, especially when leveraging synthetic training aids and virtual reality.

Phase Three: Retain and Preserve

Important factors that should be retained and preserved are: • Improvements in deployed medical care; • Rehabilitative and regenerative medicine; • Human performance in extreme environments and physiological monitoring;

• Phase Two: Select, Train

• Evidence-based interventions for health and wellness;

• Phase Three: Retain and Preserve

• Stress and psychological support; • Suicide prevention programs;

It further identifies four central concerns affecting human performance throughout the whole operator lifecycle: physical, mental, emotional, and cognitive issues.

Overall, the compiled work presented in the report offers a solid framework for ensuring informed and evidence-based decisions are made on effectiveness, preparation, and preservation of current and future SOFs. The content of this report provides insights into each phase of the operator’s lifecycle.

Phases One and Two: Identity, Prepare, Assess

The principal factors driving recruitment and personnel shortages are: • Organizational structure, roles, mandates, and the nature of the work; • Demographics; external job market factors; • Geographical factors; • Legislation affecting compensation and incentivization; • Personal life factors; and • Professional life factors.

Technological advances in selection tools and greater awareness of diversity in the selection pool are crucial factors in improving recruitment, retention, and effectiveness.

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• Mental health and mental performance programs; • Cognitive load and cognitive performance; • The effects of impact and environmental exposure; • The importance of continuous and data-driven monitoring of retention, workplace culture, and operator skill preservation; and • Support for the transition to civilian life.

One of the key themes identified in the report is how the future landscape of warfare and associated human factors are driven by the adoption of Emerging and Disruptive Technologies (EDTs). Advances in biotechnologies, human augmentation, and AI heavily influence the SOF lifecycle and human performance.

The significant amount of research and analysis across human (military) performance issues is noteworthy, considering the novelty and openness of the subject. Indeed, interest has rapidly spread on the topic, and ongoing work will further contribute to understanding and addressing human performance challenges. While much of this work is being conducted with respect to the general military population, it is applicable to the Special Forces community and its unique needs.

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TABLE OF CONTENTS EXECUTIVE SUMMARY

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INTRODUCTION

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METHODOLOGY

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PHASES ONE & TWO: IDENTIFY, PREPARE, ASSESS, SELECT, TRAIN

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OVERVIEW

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STO RESEARCH ACTIVITIES

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ASSESSMENT, SELECTION AND RECRUITMENT

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TRAINING

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PHASE THREE: RETAIN, PRESERVE

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OVERVIEW

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STO RESEARCH ACTIVITIES

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PHYSICAL HEALTH

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MENTAL AND EMOTIONAL HEALTH

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MENTAL AND COGNITIVE PERFORMANCE

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IMPACT AND EXPOSURE EFFECTS

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RETENTION AND SKILL PRESERVATION

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RETIREMENT FROM THE MILITARY

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CONCLUSION

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APPENDICES

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APPENDIX A: ABBREVIATIONS & ACRONYMS

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TABLE OF CONTENTS

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INTRODUCTION

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INTRODUCTION The Special Forces community provides unique and highly prized capabilities within Alliance forces. However, the last twenty years of constant deployments have highlighted significant human performance concerns across the entire operator lifecycle. These include physical, mental, emotional, and cognitive issues spanning the operator’s lifecycle from assessment and recruitment to training, force preservation, and retirement. While few of these issues are unique to the Special Forces community, they often manifest more acutely due to the highly specialized and extreme nature of Special Forces Operations.

This review report consolidates the STO’s evidence base since 2012 on human performance topics centred on the three critical operator lifecycle phases identified by NSHQ. These capture the entire operator lifecycle and are as follows: • Phase One: Identify, Prepare, Assess • Phase Two: Select, Train • Phase Three: Retain, Preserve Much of this research applies to all military personnel. However, this report seeks to place this more general research in the context of Special Forces. As such, the work illustrated in this document provides a solid and evidence-based framework to ensure that informed and evidencedbased decisions are made on the optimal effectiveness, preparation, and preservation of the current and future SOF operational force.

To better understand and mitigate such issues, NATO Special Operations Headquarters (NSHQ) examines human performance and force generation best practices, and combines the lessons learned into the NATO SOF Doctrine (Project Odysseus). To support this effort and inform senior leadership within the Special Forces community, the NATO Science and Technology Organization (STO) has reviewed relevant human performance research conducted within its Programme of Work (PoW) in human performance.

The aim is to provide the Special Forces community with relevant insights and highlight opportunities for future collaboration between NSHQ and the STO.

Identify, Prepare, Assess Assessment, personnel selection and recruitment challenges.

Select, Train Personnel training, training programmes and training augmentation.

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Retain and Preserve The retention and preservation of fighting force across the SOF life-cycle and the human performance issues. a.

Physical health in terms of injuries and medical treatments, human performance in hostile environments, health monitoring and intervention. b.

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Retirement from the military and veterans’ transition to civilian life. Considering postservice wellbeing and functioning.

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SOF Lifecycle

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Retention data metrics, policy and culture and skill preservation of the fighting force.

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Impact and exposure effect on the operator to threats such as blast, high-speed impact and hypobaric.

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Mental and emotional health tools and technologies for the operator stress and psychological support.

Mental and cognitive performance enhancement (or load reduction). Mental health and performance. Cognitive load and performance.

Figure 1: The SOF operator lifecycle and the human performance issues – OCS’s elaboration of NSHQ

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Methodology

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Insight is based on the multi‑national research expertise leveraged within the STO’s Collaborative Programme of Work (CPoW). Relevant research activities from the CPoW were located using database keyword searches, and these activities subsequently form the evidence base of this review and inform its conclusions.

It should be stressed that the CPoW activities identified in this report are not exhaustive. This shortcoming is due to the limitations of the database keyword searches used to identify activities relevant to human performance challenges and the decision only to consider the last decade of CPoW research (i.e., since 2012).

However, the set of identified reports and activities is expected to be representative and cover the majority of the research undertaken within the CPoW. Relevant activities were located through searching keywords identified for relevance to a particular phase. This search relied on the free text fields written in the Technical Activity Proposal (TAP) cards for each activity. Such a methodology naturally has limitations owing to what was written in the TAPs and what keywords were searched.

In addition, to ensure the most up‑to‑date and relevant research was produced from these database searches, the decision was made to only consider activities from the past decade (i.e., since 1 January 2012) and those conducted under the Human Factors and Medicine (HFM) and Systems Analysis and Studies (SAS) Panels.1 Lastly, to optimise the search results, the TAP text fields included in the search were limited to the activity ‘Title’, ‘Topics’, ‘Objectives’, and ‘Military Relevance’. The activities were then manually filtered for their relevance to human performance issues.

1 R esearch in the STO CPoW is undertaken by a Panel or Group, of which there are several. These are: the Applied Vehicle Technology (AVT) Panel; Human Factors and Medicine (HFM) Panel; Information Systems Technology (IST) Panel; System Analysis and Studies (SAS) Panel; Systems Concepts and Integration (SCI) Panel; Sensors and Electronics Technology (SET) Panel; and the NATO Modelling and Simulation Group (NMSG).

Some activities were determined to be outside of the scope of this exercise. These include activities examining biotechnological interventions and the application of other Emerging or Disruptive Technologies (EDTs) for human augmentation. In addition, activities related to Chemical, Biological, Radiological, and Nuclear (CBRN) challenges and those related to questions of sex and gender are also excluded from this review. However, the NATO Chief Scientist (OCS) has produced two comprehensive reports on these areas.2 Interested readers may wish to consult these for further information, particularly the report on ‘Women in the Armed Forces,’ which contains a detailed breakdown of the issues and challenges faced for the optimal deployment of women in the armed forces. Many of the challenges identified in this report apply to the SOF environment.

This review report provides an overview of STO research on human performance issues based on the operator lifecycle phases as follows: • Phase One: Identify, Prepare, Assess • Phase Two: Select, Train • Phase Three: Retain, Preserve Each phase is considered in sequence, presenting an overview and summary of STO research related to that phase. For example, since there is limited STO research on assessment, selection, recruitment, and training, Phases One and Two are considered parallel.

2 N ATO Chief Scientist Research Reports on ‘Women in the Armed Forces’ and ‘The Impact of Technological Trends on CBRN Defence Towards 2030.’ Both of these reports can be found on NATO Docs.

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Phases One & Two: Identify, Prepare, Assess, Select, Train

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OVERVIEW Phases One and Two refer to research that considers the assessment, selection, and recruitment of operators. Phase Two also considers the training of the operator. These Phases are here considered together, reflecting shared focus areas across the phases and the limited volume of relevant CPoW research to these areas. Many of the research activities detailed below are still ongoing.

Key themes in the research include: • The complicated context surrounding recruitment and personnel shortages; and • The development of increasingly comprehensive training programmes to enhance operator effectiveness (e.g., through the adoption of synthetic training aids).

Pertinent to these issues is the NATO Chief Scientist Research Report on ‘Women in the Armed Forces’, published in 2021.3 The report offers relevant insights regarding the influence and impact of sex and gender on operator assessment, selection, recruitment processes, and training programmes. The report supplements the research detailed below, and readers should consult this for further detail.

STO RESEARCH ACTIVITIES ASSESSMENT, SELECTION AND RECRUITMENT Research conducted by the STO has examined recruitment challenges and personnel selection.

A Research Task Group concluding in 2021 addressed personnel shortages in the military workforce and responses to this challenge.4 Diverse reasons for personnel shortages include private‑sector competition, work‑life imbalances, compensation, personnel policies, management, career opportunities, and perceived shortcomings in employer attractiveness. Seeking to understand better the nature of these personnel challenges and how to detect and respond to them, the group modelled the use of Reserve Forces to achieve higher efficiency and compiled information on personnel shortages from four nations (Canada, Norway, Sweden, and the United Kingdom). The information collected on personnel shortage occupations noted that military personnel systems and data gathering varies between countries.

Therefore, it is not straightforward to apply what has been successful in one country to another.

However, some common ground between the four countries was observed: shortages in engineering and technical trades, as well as piloting, logistics, and medical occupations seem to be experienced by two or more of the countries.

The Task Group also defined a conceptual model of the response to personnel shortages. This model covers the identification of a shortage, the characterisation of the problem (i.e., identifying the specific stage of the personnel cycle and which drivers underlie the shortage), and finally moves on to mitigation strategies.

Figure 2: Personnel recruitment and training (Credit: PXFuel)

3 This report can be found on NATO Docs.

4 M odelling Personnel Flows and Identifying Potential Solutions to Recruiting and Retention Challenges’ (SAS‑128).

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Determining that the creation of customised mitigation strategies is suitable for a specific (i.e., national, and occupational) shortage context, the group did not define a particular set of mitigation strategies to address shortages. However, the Task Group did identify the following list of ‘drivers’ that are known to underlie personnel shortage problems and which provide a holistic picture of the context surrounding this organisational challenge: • Changes to the organisation including organisational structure, roles, mandates, and the nature of the work;

Meanwhile, research is being undertaken by an ongoing Research Task Group into military personnel selection.5 This Task Group seeks to explore solutions to address the emerging needs and goals affecting military selection practice.

Indeed, military personnel selection is challenged by emerging societal and technological changes, including: • An increasingly diverse applicant pool; • Technological advances in assessment tool development such as computerised or online testing; and • Demands for assessing a range of knowledge, skills, and abilities pertinent to reliable and dependable personnel performance.

• Demography of the occupation; • External job market factors; • Geographical factors; • Legislation, such as that which affects compensation and may unintentionally incentivise individuals to leave or not join in the first place;

Concluding in March 2022, this Task Group will contribute to the exploration, generation, and documentation of viable solutions to address the aforementioned emerging challenges.

• Personal life factors; and

TRAINING

• Professional life factors.

STO research examining personnel training is framed around two key themes:

Canada also contributed a supplementary literature review investigating the effectiveness of monetary incentives as a targeted remedy for occupations experiencing recruitment and retention challenges. This literature review indicated that, broadly, incentive pay does correlate with improved military recruitment rates.

This finding supports the use of cash incentives.

However, the author of the literature review noted that military personnel are a heterogeneous population and incentive pay will have varying effects on those in different occupations.

• Training programmes; and • Training augmentation using synthetic technology.

Regarding training programmes, STO research in this area is limited yet wide‑ranging. Four completed or ongoing activities examine various aspects of the operator’s comprehensive training programme: • ‘Emerging Technological Advances in Tactical Casualty Care’ (HFM‑249); • ‘Reducing Musculo‑Skeletal Injuries’ (HFM‑283); • ‘Psychosocial Factors of Unconventional Warfare’ (HFM‑ET‑190); and • ‘SWEAT (Soldier System Weapon & Equipment Assessment Tool)’ (SAS‑145).

5 ‘ Advances in Military Personnel Selection’ (HFM‑290).

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The Exploratory Team HFM‑ET‑190 is working to assess whether a further STO research activity on the psychosocial factors of unconventional warfare would be feasible. To engage with and influence civilian populations, special operations forces need an understanding of human factors and the ability to incorporate those factors into training and planning to conduct partnership activities and operations. To help address the unconventional warfare gap between NATO and its adversaries, this team is evaluating the problem space and identifying potential areas for further investigation and investment to inform NATO’s special operations force development and training.

This activity is due to conclude in July 2022.

Figure 3: Personnel training programmes and training augmentation with artificial technology (Credit: iStock)

The symposium HFM‑249, held in April 2015, examined the development and fielding of advanced medical technologies to understand soon‑to‑be fielded technologies and determine how they can best be applied within the multi‑national NATO environment. Amongst other findings, it concluded that there is an urgent need for the standardised training of all staff managing casualties, all the way from soldiers’ pre‑deployment to the medical staff handling the damage control resuscitation, to the surgeons.

The ongoing Research Task Group (RTG) HFM‑283 was formed to examine Musculoskeletal injuries (MSkI) in the military population and identify effective preventative measures. MSkI are a particular risk for new recruits as they begin military training programmes and include muscle pain resulting in days lost training through to stress fractures resulting in medical downgrading or medical discharge. This activity will conclude in April 2022 and will contribute to the nations’ understanding and prevention of this condition.

Finally, the ongoing Research Task Group SAS‑145 is examining the optimisation of small arms capability using an overall system approach encompassing the following integrated components: training, human factors, weapons, ammunition, optics and enablers, and soldier equipment. For example, it is well understood how to test a rifle and ammunition in isolation, but not how to assess ‘Soldier in the Loop’ performance as part of the overall ‘Soldier System’ and relate it back to operational effectiveness. SAS‑145 brings together researchers across various disciplines to develop relevant assessment methodology and metrics; the activity proposes that these tools could be utilised across the spectrum of materiel developers, science and technology communities, and training and doctrine organisations. This assessment methodology would then permit NATO to optimise ‘Soldier System’ readiness, lethality, and survivability, thus optimising investment (including training programmes). This activity is due to conclude in October 2022.

STO research on operator training augmentation using synthetic technology is also limited, with most activities still ongoing.

Four completed or ongoing activities examine various aspects of training augmentation technologies: • ‘Workshop on Advanced Medical Technologies in Training’ (HFM‑267); • ‘Assessment of Augmentation Technologies for Improving Human Performance’ (HFM‑297); • ‘Optimization of Investment in Simulation‑Based Military Training’ (SAS‑136); and • ‘Assessment of Factors Impacting Cybersickness’ (HFM‑MSG‑346).

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The research workshop HFM‑267, held in 2016, examined advanced training technology (e.g., simulation, serious gaming, and augmented reality) to improve first responders’ medical training. The activity recognised an urgent need for the standardised training of all staff managing casualties, from the soldiers on the ground to the first‑responder medical staff, and finally to the surgeons. Therefore, the workshop aimed to investigate the potential for and limitations of advanced medical technologies in first response training to support primary care skills and mental resilience in stressful, extreme conditions. During an interactive workshop with demonstrations and hands‑on sessions, it was noted that advanced training technology for combat and primary care is inhibited by a lack of metrics for standardisation and validation. Improvement is also needed in this area in terms of international collaboration and also between the Information Technology, engineering, and healthcare sectors.

Meanwhile, the sessions examining advanced training technology for mental resilience focused on measuring and validating stress, the de‑stigmatisation of mental training, and technology development for serious games, VR, and apps.

Similarly, in the context of the maturation of various augmentation technologies, the ongoing Research Task Group HFM‑297 contributes to the Alliance’s understanding in this area.6 The group is reviewing and analysing opportunities for the use of new and emerging augmentation technologies in training and operations to improve learning, performance, retention, and the overall transfer of skills from the training to the operational environment. This activity is due to conclude in June 2022.

Moreover, two ongoing research activities examine additional factors when considering the augmentation of operator training programmes using synthetic technology: financial investment and operator cybersickness.

In the context of limited defence budgets, the Research Task Group SAS‑136 is developing a roadmap to optimise investment in simulation‑based training and identify deficiencies, gaps, challenges, and best practices among NATO nations. Concluding in March 2022, it is anticipated that the resulting findings from this group may be used to enhance the ability of NATO forces to maximise training effectiveness within the context of limited defence resources.

Meanwhile, Research Task Group HFM‑MSG‑346, a joint effort between the HFM Panel and the Modelling & Simulation Group (MSG), examines how to better understand and predict individual cybersickness susceptibility when using immersive virtual environments such as Virtual Reality (VR) goggles. Building on previous STO research on the mitigation of cybersickness in VR systems, this condition may have undesirable consequences beyond the sickness itself, including discouraging personnel from participation in such training and reducing training efficiency. Due to conclude in October 2024, this research activity will contribute to our understanding of where a VR‑based system can be successfully used in training.

6 These include augmented reality, virtual reality multimodal immersion, and assisted cognition.

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Phase Three: Retain, Preserve

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OVERVIEW This phase considers research that examines the retention and preservation of the fighting force.

Across the CPoW, there is a wide range of research activities considering aspects of retention and preservation across the entire operator lifecycle and the associated human performance issues.

These include: the physical and mental health of the operator; cognitive performance and augmentation; the effects of blast impact and exposure; skill fade; and retention. The CPoW also contains research related to retirement from the military and the transition to civilian life at the conclusion of the operator lifecycle.

• Evidence‑based interventions for health and wellness;

In this way, the CPoW provides a solid evidence‑based framework for ensuring informed and evidence‑based decisions are made on the optimal health, effectiveness, retention, and preservation of the current and future SOF operational force.

• Support for the transition to civilian life.

Across the range of STO research examining this Phase, critical themes in the research include: • The quality assurance and standardisation of the deployed medical system;

• Stress and psychological support; • Suicide prevention; • Mental health and mental performance; • Cognitive load and cognitive performance; • The effects of impact and exposure on the operator; • The importance of monitoring retention, broader workplace culture, and operator skill preservation; and

As previously mentioned, pertinent to these issues is the NATO Chief Scientist Research Report on ‘Women in the Armed Forces’, published in 2021.7 The report offers relevant insights regarding the influence and impact of sex and gender on retention, force culture, as well as the operator’s physical and mental health. In addition, the report supplements the research detailed below and readers should consult this for further detail.

• Rehabilitative and regenerative medicine; • Human performance in extreme environments and physiological monitoring; 7 This report can be found on NATO Docs.

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STO RESEARCH ACTIVITIES PHYSICAL HEALTH The largest body of research in the STO CPoW focuses on the physical health of the operator.

This research offers a significant breadth of topics, ranging from injury and medical treatment, human performance in extreme climate operations, health monitoring, and interventions for health and wellness.

Figure 4: Soldier performing a medical treatment procedure in a hostile environment (Credit: iStock)

In the field of injury and medical treatment, research within the CPoW has holistically examined the deployed medical system in the field through to the rehabilitation of the operator.

STO research on the in‑field response to injuries is limited, focusing instead on the assurance and standardisation of the deployed medical system.

Two Exploratory Teams examine this area: • ‘Development of an Accepted and Comparable System of Indicators of Performance and Best Practices for the Deployed Medical System’ (HFM‑ET‑140); and • ‘Treatment Challenges with Combined Injuries’ (HFM‑ET‑191).

The Exploratory Team HFM‑ET‑140, completed in 2017, explored quality assurance for the deployed medical system through data collection from various missions and by analysing treatment outcomes. This activity is essential as NATO medical services are missing an accepted and comparable system of performance indicators and best practices for the deployed medical system.

Unfortunately, there is no follow‑on research activity from this Exploratory Team at the time of writing.

The ongoing Exploratory Team HFM‑ET‑191 is working to assess whether a further STO research activity on combat trauma treatment evaluation platforms for multi‑domain operations is feasible.

Multi‑domain operations call for a synchronised military medical approach that has considered the multiple factors contributing to treating the complex casualties on this expansive battlefield.

The synchronisation of standards of care for wounded warfighters would offer various benefits, allowing a rapid return to battle, the preservation of the fighting force, and the conservation of medical assets. This activity is due to conclude in October 2022.

As a vital next step in terms of the complete recovery and redeployment of the operator, STO research has also examined rehabilitation and regenerative medicine.

For example, a research symposium held in April 2013 aimed to share national experiences and best practices for sustaining operator physical and mental health across the operational spectrum.8 Presentations focused on topics including technology‑guided treatments and the rehabilitative use of virtual reality, with discussions emphasising the ethical and moral obligation of healthcare providers to provide both rehabilitation as well as the overall prevention of operator injury and disease.

8 ‘ Force Sustainment: Rehabilitation, Regeneration and Prosthetics for Re‑Integration to Duty’ (HFM‑228).

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Similarly, a workshop held in May 2014 provided an overview of the latest research in the field of Regenerative Medicine. Presentations identified the unique military needs ranging from gunshot wounds, large soft tissue and bone defects, nerve injuries, infections, traumatic amputations and (infected) non‑unions. The workshop developed the foundation of an international network of experts in the field of Regenerative Medicine to bring forward new therapies to enhance the recovery of those wounded in action.

Focusing on this prevention aspect, the Task Group HFM‑229 looked into optimising hearing loss prevention and the rehabilitation of soldiers with a hearing impairment.9 The group detailed how precise acoustic communication is a significant factor for fitness for duty, particularly in noisy environments and multi‑national military operations with both English native and non‑native communicators. Consequently, the group recommended that NATO develop and validate realistic speech tests to improve communication in multi‑national military environments and undertake further research in acoustic communication quality on the following areas:

Particularly relevant to the Special Operations Forces context, various ongoing research activities concerning medical treatment and human performance in extreme climate operations were undertaken. These activities will contribute to our understanding of human performance in extreme environments and how to prevent illness: • ‘Human Performance and Medical Treatment and Support During Cold Weather Operations’ RTG (HFM‑310); • ‘Human Performance and Medical Treatment and Support During Cold Weather Operations’ Symposium (HFM‑349); and • ‘Development of a NATO STANREC for Physiological Status Monitoring to Mitigate Exertional Heat Illness’ (HFM‑327).

• Auditory readiness; • Fitness for duty criteria; • Hearing rehabilitation (bringing soldiers back to work); • Communications quality and assessment in Military surrounding; • Assessing speech understanding in an international context; and • Protection and epidemiology.

9 ‘ Optimizing Hearing Loss Prevention and Treatment, Rehabilitation and Reintegration of Soldiers with Hearing Impairment’ (HFM‑229).

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Figure 5: Human performance and medical treatment and support during cold weather operations – HFM‑310 (RTG)

Research Task Group HFM‑310 is exploring new concepts to prevent and treat non‑freezing injuries (i.e., hypothermia) and freezing injuries (i.e., frostbite). Parallel solutions to Arctic/cold medicine, including human nutrition and human performance enhancement technologies (including advanced textiles), are also being explored and tested, with collaborative field trials anticipated.

Due to conclude in March 2023, this research group will inform future improvements in operator sustainability and effectiveness during deployment in extreme cold operational environments.

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Simultaneously, complementing the HFM‑310 Research Task Group, the symposium HFM‑349 will contribute to our understanding of deployment in extreme cold operational environments. Due to be held in 2022, this symposium will bring together researchers in this area to discuss cold medicine and performance.

STO research has also focused on operator adaptation to extreme heat environments.

For example, Research Task Group HFM‑327 is exploring the development of a NATO Standardization Recommendation (STANREC) for physiological monitoring to diminish exertional heat illness. Exertional heat illness represents a significant risk to life, chiefly due to high‑intensity military training activity and the requirement to wear personal protective equipment and carry extreme loads. Thus, the ability to monitor individuals and assess individual thermal risk will considerably lower this risk. It will also allow for an improved training experience, where military trainers can better pace activities for better training outcomes. Therefore, this team is developing a STANREC to enable alignment across member nations for real‑time Physiological Status Monitoring (PSM). This activity is due to conclude in March 2023.

Indeed, the STO has undertaken dedicated research into operator health monitoring.

Figure 6: Enhancing warfighter effectiveness with wearable bio sensors and physiological models – HFM‑260 (RTG)

A symposium held in October 2015 focused on health surveillance and medical informatics.10 In assessing the state‑of‑the‑art in this area, the symposium covered a variety of related issues, including research on the technology necessary for the sustainment of adequate public health systems and population health, human factors integration, and various types of medical and health surveillance (e.g., syndromic surveillance, life course health surveillance). The symposium concluded that progress is moving quickly in medical informatics as information management improves. However, particularly as the last NATO symposium on this topic was 11 years ago, the symposium determined that a multiyear program of technical interchange and capability analysis would be valuable to NATO’s health surveillance and informatics. One key recommendation was the need to validate the core NATO deployment health surveillance system, EpiNATO‑2. Improved communication between NATO’s Deployment Health Surveillance Centre (DHSC) and senior medical authorities in theatre was also noted.

Meanwhile, a Research Task Group concluding in July 2019 looked at physiological monitoring, which has many potential applications for the military as an actionable real‑time health and performance status of individual soldiers can be provided to the individual, leaders, and medical personnel.11 Building on earlier STO research in this area, RTG HFM‑260 took this to the next level, coordinating national efforts in physiological monitoring applications, two multi‑national field research experiments, and three Cooperative Demonstrations of Technology. This team highlighted the specific military character of operator wearable technology and, as a result, the need for dedicated research on the development of physiologically‑based algorithms and iterative testing with soldiers in realistic field environments.

Thus, it is left to the military to fill critical gaps in the design and application of soldier sensor systems that the commercial sector may not otherwise address.

10 ‘Health Surveillance and Informatics in Missions: Multidisciplinary

Approaches and Perspectives’ (HFM‑254).

11 ‘Enhancing Warfighter Effectiveness with Wearable Bio Sensors and Physiological Models’ (HFM‑260).

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In a similar vein, an ongoing Task Group is looking into detecting, preventing, and treating illnesses developed due to operational stressors.12 Looking to address this challenge, the RTG seeks to prove that integrating high computational power with genomics is a viable tool that may be implemented in military medicine. The genomic data could then be linked with health data via computational tools and knowledge of the effects of operational stressors on a soldier’s health and performance.

This assessment would provide military medicine with an integrative platform whereby mental and physical performance could be examined through an evidence‑based approach. This activity is due to conclude in April 2023, when a report will be published detailing the results, challenges, successes, and way forward.

Sustaining the breadth of STO research related to the physical health of the operator, research also considers interventions for health and wellness.

Starting at the general level, a symposium held in April 2019 considered evidence‑based leader interventions for health and wellness.13 Presentation topics included: morale and cohesion; job attitudes; climate and attitude surveys; total health and wellness; coping and resilience; and fatigue. The presentations made it evident that evidence‑based leader interventions are highly relevant at all organisational levels and contexts.

Yet, there are few demonstrated evidence‑based leader interventions for health and wellbeing at the individual, group, or organisational level.

Indeed, two concerns were highlighted during the symposium. First, there appears to be a lack of causal models related to leader behaviours and health and wellbeing. While focusing on risk and protective factors is helpful from an epidemiological perspective, such an approach does not help determine causality, which is critical for developing and validating interventions. Second, there were noticeable gaps in the presentations in terms of leader‑based interventions that have been undertaken in the operational setting. Taking these two factors into account, the symposium determined that one of the most significant barriers to developing evidence‑based leader interventions for military health and wellbeing is conducting rigorous and well‑controlled studies. Recommendations were made on establishing technical activities that the HFM Panel might consider.

12 ‘ Big Data In The Military: Integrating Genomics into the Pipeline of Standard‑Care Testing & Treatment’ (HFM‑294).

13 ‘Evidence‑Based Leader Interventions for Health and Wellness’ (HFM‑302).

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Moreover, STO research considers a comprehensive range of specific interventions to support operator health and wellness. These include 3‑D scanning for clothing fit and logistics;14 the development of military loading exposure guidelines;15 and operator nutrition.16 Much of this research is still ongoing, to be completed in the 2024 ‒ 2025 timeframe.

MENTAL AND EMOTIONAL HEALTH In the critical study of mental and emotional health, some research has been conducted within the STO on tools and technology for operator support.

STO research examining mental and emotional health is framed around two key themes: • Stress and psychological support ; and • Suicide prevention.

Figure 7: Mental and emotional health – stress (Credit: iStock)

Regarding stress and psychological support, a Technical Course held in March 2019 hosted a US Air Force Research Laboratory presentation on the Special Forces context and PTSD.17 This presentation emphasised how, in this population, those compliant with treatment have the most effective reduction in symptoms, with the most effective treatment being exposure‑based therapy with a trained professional. It also noted that flight doctors should work closely with a psychiatrist and psychologist and monitor healthy lifestyle changes, including exercise, relaxation, the maintenance of healthy relationships, and healthy eating.

14 ‘3D Scanning for Clothing Fit and Logistics’ (HFM‑266).

15 ‘ Development of Military Loading Exposure Guidelines for Prevention of Chronic Traumatic Encephalopathy’ (HFM‑338).

16 ‘ Performance Nutrition for Fresh Feeding during Military Training and Operations’ (HFM‑325); ‘Diet Supplementation for Military Personnel’ (HFM‑326); and ‘Microbiome Applications in Human Health and Performance’ (HFM‑358).

17 Technical Course ‘Aerospace Medicine: Forward – Together RAMS USAF/ NATO STO HFM’ (HFM‑309); Presentation: ‘Posttraumatic Stress Disorder in U.S. Air Force Aviators and Special Forces Operators’ by Kevin F. Heacock, Lt Col, USAF, MC, FS Teg McBride, Lt Col, USAF, BSC, ABPP. 19 March 2019.

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Related to this, the ongoing Research Task Group HFM‑329 is exploring the provision of psychological advice and guidance for leaders across the deployment cycle.18 The group are reviewing current evidence and best practice to update and produce a new psychological guide for leaders across the deployment cycle in support of greater standardisation and interoperability, improved knowledge for military leaders, enhanced psychological fitness, and ultimately a more robust fighting force across the NATO nations. This activity is due to conclude in March 2023.

Regarding suicide prevention, STO research in this area is limited.

The symposium HFM‑27519 brought together researchers in April 2017 to discuss this topic across three main areas: best practices and deployment factors; risk and protective factors for military suicide; and models and research issues for military suicide prevention. The symposium highlighted the complex problems associated with establishing any causality assessment for approaches to reduce suicide. This hurdle is likely due to the complexity of suicide coupled with the relatively rare occurrence. Moreover, the problem with comparing suicide rates between nations was discussed and discouraged, mainly as there exist differences in case definition, determination of suicide, military structure, and numerous other factors. However, the outcomes of national prevention programs often have ancillary benefits and should continue. Furthermore, it was highlighted that individual NATO nations should collect data on their militaries regarding deployment and non‑deployment exposure and mental health outcomes and identify specific populations within the military who may have a concentration of risk.

The symposium also noted an interesting emerging trend, embraced by several nations, to directly target suicidality as the focus of clinical intervention instead of a singular focus on underlying diagnoses. Studies are underway to demonstrate efficacy. The symposium’s Technical Evaluators also noted the absence of any discussion during the symposium on the biological correlates of suicidal behaviour and suicidal risk.

However, epidemiological studies, especially twin studies, have established that suicidal behaviour is partly heritable. Therefore, the Technical Evaluators encouraged further research attention on heritability and neurobiological perspectives on suicide.

18 ‘ A Psychological Guide for Leaders Across the Deployment Cycle’ (HFM‑329).

19 ‘Suicide Prevention’ (HFM‑275).

Meanwhile, related to HFM‑329, the Task Group HFM‑277 (concluding in December 2022) has explored leadership tools for suicide prevention.20 The group have undertaken the following scientific objectives, with a technical report to follow soon: • Gain an enhanced understanding of the unique needs of leaders in the area of military suicide prevention and the perceived challenges through confidential interviews, focus groups, and surveys; • Prepare a series of decision‑making aids and tools in suicide prevention that directly address the stated needs of leaders in the area of military suicide prevention; and • Disseminate gained knowledge and best practices to NATO leadership and members.

MENTAL AND COGNITIVE PERFORMANCE In terms of mental and cognitive performance, STO research in this area is largely ongoing, likely reflecting both the novelty and pertinence of this area.

STO research in this area is framed around two key themes: • Mental health and mental performance; and • Cognitive load and cognitive performance.

Regarding mental health and mental performance, two Research Task Groups examine this area: • ‘Optimizing Human Performance in NATO SOF Personnel Through Evidence‑Based Mental Performance Programming’ (HFM‑308); and • ‘Personalized Medicine in Mental Health and Performance’ (HFM‑281).

20 ‘Leadership Tools for Suicide Prevention’ (HFM‑277).

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STO research on cognitive load and cognitive performance focuses on alleviating operator mental fatigue and augmenting overall performance.

Four ongoing or completed activities examine this area: • ‘Applying Neuroscience to Performance: From Rehabilitation to Human Cognitive Augmentation’ (HFM‑334); • ‘Cognitive Neuroenhancement: Techniques and Technology’ (HFM‑311); • ‘Measuring the Cognitive Load on the Soldier’ (HFM‑319); and

Figure 8: Applying neuroscience to performance: from rehabilitation to human cognitive augmentation – HFM‑334 (RSY)

Focusing on the Special Forces context, Task Group HFM‑308 seeks to identify best practices and develop a common framework for mental performance optimisation through evidence‑based cognitive performance programming, particularly under critical high‑stress situations. NATO SOF Operators must perform a broad range of physically and mentally challenging and specialised training and missions, often in austere and ambiguous environments. While most SOF organisations have a robust physical fitness training programme, mental performance programming is less common, if present at all. This Task Group is thus working on reviewing emerging and established SOF cognitive performance programmes to identify best practices and knowledge gaps. This activity concluded in June 2022, with a report to soon follow.

Task Group HFM‑281 seeks to explore Precision Health and Performance as an approach that considers and, where possible, leverages individual variations in biological makeup, history, environment, and lifestyle for disease prevention, diagnosis, and treatment, as well as optimisation of military performance. The main objective is to harness and encourage new advances in personalised approaches. This approach will optimise mental health (including the prevention and treatment of disorders and return to duty) and mental health aspects related explicitly to military‑relevant mission performance (e.g., focused concentration and mental endurance).

The primary outcome of this RTG will be the identification of cutting‑edge precision medicine techniques. This activity is due to conclude in April 2023.

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• ‘Biomedical Bases of Mental Fatigue and Military Fatigue Countermeasures’ (HFM‑331).

The symposium HFM‑334 (held in October 2021) brought together researchers to discuss the use of innovative neuroscience methods and applications in the military field with the following aims: • Enhancing the cognitive and motor performance of individuals and teams (e.g., by the use of non‑invasive stimulation techniques); and • Preventing and managing emotional stress to improve psychological wellbeing (e.g., by the use of augmented and virtual reality).

Presentations covered the possible use of neuroscientific tools for screening, assessment, health promotion and prevention, and treatment in the military field. These include non‑invasive stimulation techniques, biofeedback techniques, physiological assessment, Brain‑Computer Interface, Virtual and Extended Reality, and wearables. A key finding is that some of the presented tools (such as virtual and enhanced reality) already have enough empirical support to increase job performance resilience and reduce the risk of developing psychiatric and neurological symptoms in military personnel. However, other tools (such as non‑invasive stimulation techniques) hold potential. Still, they need further investigation before being used by military personnel as the field is not mature enough. Furthermore, the validation studies of these neuroscientific tools need to be conducted outside the laboratory because the environment where they will eventually be applied is extraordinarily unpredictable and uncontrollable.

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Indeed, cognitive enhancement techniques such as cognitive training, nutritional supplements, and non‑invasive brain stimulation techniques are of growing interest to many NATO countries to maintain a strategic performance advantage over adversaries. Accordingly, Research Task Group HFM‑311 is establishing a group of experts in these areas from across the NATO nations. This network will facilitate the exchange of state‑of‑the‑art knowledge, explore game‑changing technologies that enhance aspects of cognition, determine military capability and scientific research gaps, determine paths to military deployment for new technologies (including safety and ethical considerations), and overall recommendations for use to the operational communities. This activity is due to conclude in December 2023.

Meanwhile, Task Group HFM‑319 seeks to produce a way ahead on cognitive load measurement for NATO. The group’s primary aim is to establish a NATO consensus on strategies to measure soldier cognitive load and determine its effects on soldiers’ effectiveness. Based on experimental activities in laboratory and field settings, the group seeks to develop, test, and validate a set of cognitive load measurement systems. This activity is due to conclude in June 2023.

Related to the above activity, Task Group HFM‑331 is examining operator mental fatigue and endurance. The group seeks to develop specific recommendations regarding military fatigue and endurance. Such recommendations will draw on recent advances in neurobiology, neuropsychology, affective computing, and other technologies to present a modern integrated concept for NATO forces. This concept will then form the basis for new fatigue monitoring strategies and countermeasures. A Cooperative Demonstration of Technology (CDT) is anticipated at the end of the RTG to highlight an approach to enhanced warfighter endurance. This activity is due to conclude in November 2023.

IMPACT AND EXPOSURE EFFECTS A significant volume of STO research has been conducted on the effects of impact and exposure on the operator. This research includes blast exposure, high‑speed impact exposure, and hypobaric exposure. Particularly for SOF personnel, research in this area is valuable as operators may be exposed to such threats with increased proximity and frequency.

STO research since 2012 on blast exposure is wide‑ranging, covering injury assessment methods and modelling and simulation for blast‑related events, post‑concussive symptoms, and blast exposure monitoring in training and operations.

Research Task Group HFM‑193 looked at mild traumatic brain injury in an operational setting.21 Concluding in 2014, the group noted the considerable range as to how the participating NATO nations currently approach Mild Traumatic Brain Injury (MTBI), also known as concussion.

To a large extent, this may reflect the degree of exposure to potential injury mechanisms faced by their respective deployed forces as well as their relative levels of confidence that current approaches are adequate and appropriate. In addition, most of the clinical practice guidelines have been developed through expert opinion, based mainly on paradigms employed in sports literature. Few, if any, have been systematically evaluated in a rigorous methodological fashion to determine if they improve outcomes. Moving forward, the group assessed that the future endorsement of any clinical practice guidelines should have a built‑in evaluation framework to determine whether and the extent to which they are effective.

21 ‘ Mild Traumatic Brain Injury in a Military Operational Setting’ (HFM‑193).

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Meanwhile, ongoing STO research continues on blast exposure: • ‘Injury assessment methods for vehicle occupants in blast‑related events’ (HFM‑271); • ‘Blast Exposure Monitoring in Military Training and Operations (BEMMTO)’ (HFM‑ET‑192); • ‘Validation of Modelling and Simulation Methodologies for Human Lethality, Injury and Impairment from Blast‑Related Threats’ (HFM‑341); and • ‘Effectiveness of Legacy and Next‑Gen Personal Protect Equipment Against Current and Emerging Blast Threats’ (HFM‑ET‑194).

Task Group HFM‑271, completed in December 2020 and awaiting final publication, examined the definition of appropriate injury criteria and injury assessment methods for mounted warfighters based on contemporary battlefield, live‑fire, and laboratory data. This examination will inform the wider NATO community and STANAG 4569, which addresses the ballistic and mine protection levels for the qualification of vehicles and is working on updates that include the IED threat.

The Exploratory Team HFM‑ET‑192 is working to understand operator occupational health hazards resulting from the repetitive use of weapon systems and explosives throughout a military career. A secondary objective is to recommend further exploration of effective strategies to prevent, mitigate unnecessary exposures, and sustain brain health and performance. This activity is due to conclude in July 2022.

to developing effective personal protective equipment (e.g., by using objective metrics such as biomechanical perturbations and injury risk). This activity is due to conclude in September 2022.

Research is also being conducted in the CPoW on high‑speed impact exposure, addressing the range of impact and exposure effects on the operator.

The ongoing Task Group HFM‑344 is working to establish a data collection effort that will enable analysis towards identifying safe impact exposure levels for High‑Speed Boat (HSB) operators.22 This work will help inform guidance, leading to a reduction in Musculoskeletal Injuries (MSkI), safety improvements, operator readiness enhancement, and career longevity. This activity is due to conclude in October 2024.

Moreover, research is being undertaken on hypobaric exposure (i.e., decompression sickness).

A Research Task Group is looking at this exposure in relation to aviators and high‑altitude special operations personnel.23 The group seeks to understand the scope of the problem in various career fields, define the underlying pathophysiology, and recommend effective prevention and treatment protocols. This activity is due to conclude in June 2023.

RETENTION AND SKILL PRESERVATION Addressing the retention and preservation of the fighting force, STO research covers several issues in this area, including retention data metrics and policy, culture, and skill preservation.

Meanwhile, Task Group HFM‑341 is developing standardised methodologies and criteria to validate computational models and simulation approaches for the entire spectrum of blast‑related injuries. Taking a multidisciplinary scientific approach, the RTG seeks to leverage blast injury biomedical research and computational modelling efforts among the participating nations, validating a framework for translating scientific information into the capability to model human lethality, injury, and impairment across the spectrum of blast‑related threats. This activity is due to conclude in November 2024.

Lastly, the HFM‑ET‑194 Exploratory Team is researching the effectiveness of personal protective equipment against current and emerging blast threats. Cooperative research through this ET and subsequently through a follow‑on RTG will promote an understanding of the challenge and associated strategies essential

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22 ‘Human Impact Exposure Onboard High Speed Boats’ (HFM‑344).

23 ‘The Impact of Hypobaric Exposure on Aviators and High‑Altitude Special Operations Personnel’ (HFM‑274).

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A Research Task Group concluding in 2021 addressed personnel shortages in the military workforce and responses to this challenge.24 Focusing on this group’s exploration of retention challenges, the group recommends the following principles and approaches to monitor for personnel shortages and to manage them effectively: • Clearly define the personnel makeup that constitutes a healthy occupation or group and ensure that personnel management and record‑keeping support this to have an unambiguous comparison between the desired and actual state; • Incorporate additional metrics that will point to specific concerns or causes for a shortage (e.g., outflow rates, training success rates, and promotion prospects); • Report metrics consistently across all groups and over time so that comparisons can be made, and deviations flagged; • Shortage assessments should include predictive models that forecast the gap between the personnel requirement and the actual number of personnel; and • Exploring best practices for evaluating the effectiveness of mitigation actions is a compelling area for further investigation. This exploration is essential as there is typically little information or evidence to measure the effectiveness of the mitigation measure, with successes or failures chiefly being defined anecdotally.

Canada also contributed a supplementary literature review investigating whether incentive pay improves military retention. This literature review indicated that, broadly, incentive pay might correlate with improved military retention rates. This research may support the use of cash incentives, although the author noted that military personnel are a heterogeneous population and incentive pay will have varying effects.

Furthermore, particularly for the issue of retention, the author noted that caution must be used when considering these types of compensation, as the kind of personnel an organisation retains through these strategies may not be desirable and will incur additional hidden costs.

Further research is being conducted on personnel retention.25 The overall objective of this activity is to build on existing research on retention‑related issues in the Armed Forces, conduct primary empirical research, and provide an analytically rigorous understanding of this critical personnel issue. Completing this work will result in a rigorous cross‑national survey instrument to measure military personnel retention and the associated drivers. This activity is due to conclude in September 2025.

Additional issues related to retention under consideration are the broader workplace culture and ethnic tolerance.

An ongoing Task Group is researching culture and ethnic (in)tolerance in the military setting.26 The group seeks to identify the factors associated with ethnic tolerance and intolerance and their relationships to military diversity and inclusion.

Indeed, while this group’s work is also applicable to recruitment challenges, it is critical to recognise that the overall culture and how inclusive a workplace is also plays a role in personnel retention. This activity is due to conclude in June 2022.

Lastly, skill preservation is an area of ongoing research.27 This research presents a particularly salient challenge in the armed forces context.

Military training often involves the operator and their team receiving training on knowledge and skills that they may not be required to use or exercise for extended periods. Addressing this problem, the group are reviewing the categorisation of skills, factors that influence skill decay, skill decay interventions, and skill decay research methodologies. This activity is due to conclude in July 2022.

Figure 9: The transition of military veterans from active service to civilian life – HFM‑263 (RTG) 24 ‘Modelling Personnel Flows; Identifying Potential Solutions to Recruiting and Retention Challenges’ (SAS‑128). Please note this activity is detailed above in terms of its exploration of recruitment challenges.

25 ‘Personnel Retention in the Armed Forces’ (HFM‑318).

26 ‘Military Diversity: Ethnic Tolerance and Intolerance’ (HFM‑301).

27 ‘Understanding and Reducing Skill Decay’ (HFM‑292).

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RETIREMENT FROM THE MILITARY Taking into account the full operator lifecycle, limited research has been undertaken in the CPoW on operator retirement and the transition to civilian life.

A Task Group concluding in 2019 explored the transition of military veterans to civilian life.28 Transition out of the military includes a series of adjustments, including changes in location, career, relationships, family roles, support systems, social networks, and community. In addition, this transition has implications for post‑service wellbeing and functioning. Recognising that each nation is different, the essential considerations for a nation developing a military‑to‑civilian transition programme were determined as including the establishment of the following:

The group intends that these nine essential components provide a military‑to‑civilian transition framework for nations developing or enhancing the services and support they provide to service members returning to civilian life. If each component is addressed, the group is confident that each service member and their family will have the best chance for success in their transition.

Additionally, an ongoing Task Group is researching the problem of military member and veteran radicalisation.29 This activity aims to assess domestic radicalisation among NATO member and partner countries, including exploring prevalence, risk and protective factors, assessment tools, the development of prevention strategies, and policies tailored to military and veteran populations. This activity is due to conclude in February 2025.

• A transition framework that captures the key phases of transition; • A definition of ‘veteran’; • Focus on work disability prevention; • Measuring outcomes; • Timely and appropriate engagement; • Address unique health and social care needs; • Culture, recognition, and military‑to‑civilian transition; • Involvement of families in transition; and • Provide employment assistance.

28 ‘The Transition of Military Veterans from Active Service to Civilian Life’ (HFM‑263).

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29 ‘Military Service Member and Veteran Domestic Radicalization’ (HFM‑347).

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Conclusion

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This review has provided a consolidated overview of the past decade of STO research and expertise related to human performance issues, and in particular the research most relevant to the Special Forces community. It has centred on the following phases of the (special forces) operator lifecycle: • Phase One: Identify, Prepare, Assess • Phase Two: Select, Train

As we advance, the present corpus of STO expertise presents a cohesive body of evidence to understand human performance and the associated challenges to be addressed and overcome. It provides human performance guidance of particular relevance to the Special Forces community. Ongoing research will further expand this understanding, and interested readers are recommended to follow these activities’ progress.

• Phase Three: Retain, Preserve Over the last decade across this area, it is apparent that the STO has amassed a considerable body of research and analysis on human performance.

Much of the research is still ongoing but is expected to contribute to our understanding of human performance challenges in the near term.

In a nutshell, the document provides a solid scientific framework ensuring informed and evidence-based decisions are made on the optimal effectiveness, preparation, and preservation of the current and future SOF operational force.

In terms of the key findings from this review, a key theme is the range of human performance challenges and the multifaceted nature of these issues.

Key themes in the STO’s research include: • The complicated context surrounding recruitment and personnel shortages.

• The development of increasingly comprehensive training programmes to enhance operator effectiveness (e.g., through the adoption of synthetic training aids).

• The quality assurance and standardisation of the deployed medical system.

• Rehabilitative and regenerative medicine.

• Human performance in extreme environments and physiological monitoring.

• Evidence‑based interventions for health and wellness.

• Stress and psychological support.

• Suicide prevention.

• Mental health and mental performance.

• Cognitive load and cognitive performance.

• The effects of impact and exposure on the operator.

• The importance of monitoring retention, broader workplace culture, and operator skill preservation.

• Support for the transition to civilian life.

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Appendices

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APPENDIX A: ABBREVIATIONS & ACRONYMS

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CBRN

Chemical, Biological, Radiological, and Nuclear

CDT

Cooperative Demonstration of Technology

CPoW

STO Collaborative Programme of Work

DHSC

NATO’s Deployment Health Surveillance Centre

EDT

Emerging and/or Disruptive Technology/Technologies

EpiNATO‑2

NATO deployment health surveillance system

ET

Exploratory Team

HFM

Human Factors and Medicine Panel

HSB

High‑Speed Boat

IED

Improvised Explosive Device

MSG

Modelling & Simulation Group

MSkI

Musculoskeletal Injuries

MTBI

Mild Traumatic Brain Injury

NSHQ

NATO Special Operations Headquarters

OCS

Office of the NATO Chief Scientist

RTG

Research Task Group

SAS

Systems Analysis and Studies Panel

SOF

Special Operations Forces

STANAG

NATO Standardization Agreement

STO/NATO STO

NATO Science and Technology Organization

TAP

Technical Activity Proposal

UK

United Kingdom

VR

Virtual Reality

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