Table 4.
Effect of acute stress on performance in simulated environments
| Author | Year | Stress measurement technique | Timing of stress measurement | Technical skill measurement tool | Impact on technical skills | Impact on non-technical skills | Risk of Bias (1: Rob2, 2: ROBINS-I) | Author conclusions |
|---|---|---|---|---|---|---|---|---|
| Keenlyside et al. [24] | 2023 | Not measured | Not described | Time taken to complete task, distance travelled by instrument tips, handedness, average speed of instrument tips, average motion smoothness | No statistical difference in performance seen between stimuli groups. Rapid decrease in time taken for task completion in the group exposed to positive stimuli. Also increase in instrument speed and motion smoothness. Decrease in instrument speed in negative stimulus group | Not measured | Low 1 | The effect of emotive visual stimuli on surgical performance is complex |
| Zheng et al. [25] | 2022 | Not measured | Not described | Modified Observed Structured Assessment Tool, Velocity, acceleration, jerk, path length, economy of volume of instrument tip | Stressed group had statistically significant higher velocity, acceleration and jerk in both hands. Stressed group had poorer mOSATS scores (respect for tissue, instrument handling and total score). Greater stress intensity resulted in greater velocity, acceleration, jerk, path length and reduced economy of volume. Stressed group also had deterioration of performance in terms of mOSATS domains of respect for tissues, instrument handling, total score | Not measured | Low 1 |
The clinical stressors had a negative effect on surgical performance. Kinematic metrics are negatively impacted by stress conditions for both the dominant and non-dominant hands. Stressed group’s movement faster and less smooth. Control group had better performance in treating the tissue, handling and moving with the instruments |
| Bakhsh et al. [33] | 2019 | HR, R-Ri, LF/HF, NASA-TLX* | Intra-operatively, post-operatively (questionnaires) | Global Rating Scale of Endovascular Performance (GRS-E) | No global difference in technical performance, individual increased sympathetic tone was associated with poorer technical performance, however the difference was not significant | Not measured | Low 2 | A discrete, measurable increase in stress is experienced by surgeons during high fidelity endovascular simulation and differentially affects junior surgeons |
| Stefanidis et al. [39] | 2017 | STAI-6, HR* | Intra-operatively, post-operatively (questionnaires) | Objective score based on completion within cutoff time, task completion time, accuracy error, knot security error | Mental skills practice group had lower stress in transfer and retention tests (not statistically significant in retention task) although average HR was higher compared to control. Suturing performance increased in retention task in the mental skills group | Not measured | Low 1 | The mental skills practice implemented in this study effectively enhanced participants’ mental skill use, laparoscopic performance and reduced cognitive stress |
| Crewther et al. [40] | 2016 | STAI-6, salivary cortisol, HR, HRV, NASA-TLX, f-NIRS* | Intra-operatively, post-operatively (questionnaires) | Fundamentals of Laparoscopic Surgery scoring system consisting of efficiency (time), precision (errors) | Stress significantly affected task performance. Skill performance showed improvement with lower stress and workload reported at later stages. HR data exhibited lower values in the middle and post sessions compared to baseline, suggesting reduced stress. Moreover, stress and workload measures were negatively correlated with both absolute skill performance and its percentage changes over time | Not measured | Moderate 2 | A 3-week laparoscopic training program promoted stress-related adaptations supporting the acquisition of new surgical skills and many outcomes were retained after a 4-week period without further training |
| Chung et al. [22] | 2016 | MAP* | Intra-operatively | Simulator scoring | Classical music had a significant effect on reducing MAP during both the Energy Dissection and Suture Sponge tasks compared to the no music and death metal music. While there were no significant differences in simulator scores among the three groups, the physiological and perceived effects suggest that stress reduction elicited from music type | Not measured | Moderate 2 | Listening to classical music during surgical training of novice robotic surgeons was associated with a reduction in stress level as evidenced by a lowering of blood pressure. This did not impact performance scores however |
| Louridas et al. [30] | 2015 | STAI-6, HR, BP* | Intra-operatively, post-operatively (questionnaires) | Objective Structured Assessment Tool, bariatric OSATS, NOTSS |
Mental practice arm had improved technical performance (OSATS, BOSATS) overall in crisis scenario. Seven of ten trainees improved their technical performance during the crisis scenario. Mental imagery ability improved significantly following mental practice training, but not in the conventional group. No differences in objective or subjective stress levels or non-technical skills were evident |
No difference in non-technical skills between groups | Low 1 | Mental practice improves technical performance for advanced laparoscopic tasks in the simulated operating room, and allows trainees to maintain or improve their performance despite added stress |
| Berg et al. [20] | 2012 | SURG-TLX* | Post-operatively | FLS-based scoring system including time taken to complete task and errors | Increase in operating room ambient temperature increased perceptions on physical demand and distraction however no difference in technical performance | Not measured | Moderate 2 | Surgeons do report increased perceptions of distraction and physical demand from increasing ambient temperature although this does not decrease technical performance in short operative tasks |
| Poolton et al. [21] | 2011 | STAI-6, HR* | Intra-operatively, post-operatively (questionnaires) | FLS scoring including completion time, path length | Time pressure condition perceived as significantly more stressful than control or evaluation conditions. Correlation analyses showed weak associations between STAI and heart rate measures, particularly in the multitasking condition. Notably, completion time and path length analyses demonstrated significant effects of stress, with the multitasking condition resulting in slower completion times and longer path lengths compared to other conditions | Not measured | Moderate 2 | Recommended measures of stress levels do not necessarily reflect the demands of an operative task, highlighting the need to understand better the mechanisms that influence performance in surgery |
| Wetzel et al. [28] | 2011 | STAI-6, HR, HRV coefficient, salivary cortisol* | Intra-operatively, post-operatively (questionnaires) | OSATS, Observational Teamwork Assessment for Surgery (OTAS), Surgical Decision making, Number of surgical coping strategies | Tendency for lower technical surgical skills (OSATS) in control group who demonstrated increased stress | Mental practice improved OTAS performance. No significant changes in control group. Lower stress in the mental practice group improved team working skills | Low 1 |
Stress coping, mental rehearsal and relaxation training had beneficial effects on coping, stress, and nontechnical skills during simulated surgery |
| Arora et al. [26] | 2010 | STAI, Imperial Stress Assessment Tool* | Intra-operatively, post-operatively (questionnaires) | Dexterity parameters (path length, time taken, number of errors) | Stress correlated with economy of motion and number of errors. Objective stress correlated significantly with time taken, economy of motion and number of errors | Not measured | Moderate 2 | Stress impairs surgical performance on a simulator. Higher stress levels correlate with increased time required for task completion, poorer economy of motion and increased errors |
| Shuetz et al. [27] | 2008 | Skin resistance | Intra-operatively | Manual surgical skills (path length, angular path), intraoperative failures (blood loss, missing clips, vessels ripped) | Laparoscopic extensions of movement were larger in stress condition without recovery as well as cumulative deviation of degree from the optimal path compared with those showing no stress reaction or recovery from stress reaction. However fewer intra-operative failures in stress group | Not measured | Moderate 2 |
The mental load of the laparoscopic surgeon might be highly optimized by continuous activity of the sympathetic nervous system. The question of what extent or quality of stress produces adverse effects remains unclear |
| Moorthy et al. [31] | 2006 | Not measured | - | Generic Rating Scale for Technical Ability to Control Bleeding, blood loss, NOTECHs, Communications count, utterance frequency, time measures of crisis management | Novices had lower technical skill. Significantly greater blood loss in novice group. Significant differences in Time to diagnose bleeding, achieve control and laceration closure. Novices more likely to perform actions detrimental to patient safety (blind application and inappropriate use of traumatic clamps as well as more likely to focus on closing the laceration at the cost of blood loss) | No differences between junior and senior groups aside from higher number of communications per minute in the senior group | Moderate 2 | Variability in performance both in between and within the 2 groups of junior and senior surgical trainees |
| Hassan et al. [29] | 2006 | Not measured | - | time to complete the task, number of errors, economy of motion, angular path, instrument path length | Stress management strategies significantly impact laparoscopic simulator performance. Negative stress coping correlates with longer task completion time at the ‘easy’ level, while during training, it does not correlate with performance metrics. However, at the ‘difficult’ level, negative coping correlates with longer task completion time, more errors, and less efficient motion. Similarly, distraction correlates with poorer performance in the final task for time, errors and motion | Not measured | Moderate 2 | Ineffective stress-coping strategies correlate with poor virtual laparoscopic performance. The need for effective intra-operative stress-coping strategies is evident |
| Moorthy et al. [23] | 2003 | Not measured | - | Imperial College Surgical Assessment Device (measuring manual dexterity). Error scoring using knowledge-based and skill-based domains | Significant increase in the total path length of the left hand across conditions, notably under mental and auditory stressors. Significant increase in the path length per movement of both hands across conditions, particularly under tactile stress and nearly under auditory stress. Errors significantly increased under all stress-inducing conditions. Skill-based errors increased notably under mental, tactile, and auditory stress, while knowledge-based errors increased across all conditions. Significant correlation between the total number of errors and the path length per movement of both hands | Not measured | Moderate 2 | All three stressors led to impaired dexterity and an increase in the incidence of errors. Combined stressors had the greatest deterioration in performance |
*Heart rate variability metrics: HR Heart rate, HRV heart rate variability, R-Ri R to R interval, SDNN Standard deviation of inter-beat intervals, LF/HF low frequency/high frequency ratio, RMSSD Root mean squared of the successive differences between normal heartbeats
Physiological variables: MAP mean arterial pressure, BP blood pressure, f-NIRS functional near-infrared spectroscopy, NASA-TLX National Aeronautics and Space Administration Task Load Scoring, SURG-TLX Surgical Task Load Scoring, STAI State-trait anxiety index, STAI-6 Short form state-trait anxiety index