Table 3.
Effect of acute stress on performance in simulated environments
| Author | Year | Stress measurement | Timing of stress measurement | Measurement tool | Technical | Non-technical | Patient outcome | Critique | Risk of Bias (Newcastle-Ottowa) | Author conclusions |
|---|---|---|---|---|---|---|---|---|---|---|
| Anton et al. Am J Surg | 2021 | STAI-6, SURG-TLX | Intra-operatively, post-operatively (questionnaires) | Non-Technical Skills for Surgeons (NOTSS) | Not measured | Stress had negative relationship with situational awareness, decision making, mental workload, situational stress, distractions. Mental workload and situational stress negatively correlated with considering options. Overall higher stress and workload associated with lower non-technical skills regardless of experience level | Not measured | Post-procedure and self-reported measurement. Small sample size. Observer effect | NOS = 6 (moderate) | Surgeons’ stress and workload negatively affected their non-technical skills. Further, unfamiliarity contributed to surgeon stress |
| Van Houwelingen et al. Surg Endosc | 2020 | Heat Flux, METs, GSR | Intra-operatively | Task engagement (Metabolic Equivalent of Tasks, MET) | Not measured | Stress level and task engagement are affected differently between long and short procedures. Task engagement increased throughout procedure regardless of length. Surgical flow disruption is taxing on surgeons mental resources as a function of the length and nature of disruptions | Not measured | Pilot study, full detail only described for 2 cases | NOS = 6 (moderate) | Interruptions and disruptions affect novice and expert surgeons differently. Surgical flow disruption appears to be taxing on the surgeons’ mental, emotional and physiological resources; as a function of the length and nature of the disruptions |
| Grantcharov et al. BJS Open | 2019 | HRV (SDNN, RMSSD) | Intra-operatively | Generic Error Rating Tool (GERT) | Higher error rate in the highest HRV quantiles than the lowest quantiles using both SDNN and RMSSD over a 1,2 and 5-min time frames | Not measured | Not measured | Single surgeon | NOS = 3 (high) | There is an association between measures of acute mental stress and worse technical surgical performance, |
| Sexton et al. BMJ Quality and Safety | 2018 | NASA-TLX | Post-operatively (questionnaires) | Number of requests (verbal and non-verbal), anticipation and inconvenience | Not measured | Surgeon cognitive load (NASA-TLX) significantly correlated with anticipation ratio, percent of non-verbal requests and total request duration | Not defined between higher and lower stress | Observational, some parts of surgery missed due to video issues | NOS = 6 (moderate) |
Anticipation and active engagement by the surgical team resulted in shorter operative time, and higher familiarity scores were associated with fewer inconveniences. Less anticipation and non-verbal requests were also associated with lower cognitive load for the console surgeon |