Stress measurement in surgeons and residents using a smart patch
Introduction
Surgery is a stressful profession.1 Long and continuous working hours, high workload, dealing with life and death,1 and technically challenging procedures2 are common contributors to stress in surgeons and surgical residents. Chronic stress can lead to relational issues, depression, and burnout,3, 4, 5 and also increases the risk of cardiovascular disease and decreases life expectancy.6, 7, 8, 9
Surgeons and residents spend a large part of their time in the operating room. Stress can both positively and negatively affect surgeon's performance in the operating room. While moderate levels of stress are necessary to improve alertness, focus, efficiency of action and thus overall performance (‘good stress’),10 excessive and long lasting stress is known to compromise technical11, 12, 13 and non-technical skills (‘bad stress’).13 During surgical procedures, excessive levels of stress are mainly caused by technical problems, complexity of the procedure, equipment failures, patient complications, interruptions, and high workload.10, 14, 15 During laparoscopic procedures, stress is associated with a prolonged operation time,11, 12 poorer motion efficiency, and an increased number of errors.12, 16 Excessive levels of stress also impair non-technical skills such as communication,10, 17, 18 teamwork, judgment, and decision-making.10, 17 Loss of these abilities is associated with undesirable events in the operating room and could compromise patient safety.13, 14, 15, 18, 19, 20, 21, 22
Research of surgical stress has been focused on the operating room environment and stress has rarely been studied during other activities.23, 24 However, ward rounds and seeing patients in the Emergency Room, the Intensive Care Unit and outpatient clinic may also elicit stress, of which the consequences for the quality of work are unknown.
Heart rate (HR), heart rate variability (HRV), skin conductance, eye blinks, and salivary cortisol13 are objective markers for stress response. HRV in particular has shown to be a reliable and more time related measure for stress than the other markers.25 Several studies showed changes in HRV recordings in surgeons during surgical procedures, indicating an increase in intra-operative stress.24, 26, 27, 28, 29, 30, 31 Qualitative measurement of stress is commonly by self-reporting questionnaires, such as the State Trait Anxiety Inventory (STAI).32 Arora et al.33 developed a method to measure surgeons' stress during surgical procedures using the so-called Imperial Stress Assessment Tool (ISAT). By combining heart rate, salivary cortisol and STAI data, they were able to measure intra-operative stress in a reliable and valid manner. Drawbacks of this tool are the complexity, the time consuming and expensive cortisol analyses, and the inability to obtain real-time stress levels and for a longer period.
Recently, wearable sensors became available for use in healthcare, which can continuously measure vital signs such as HR in an easy and reliable way. The HealthPatch™ (Vital Connect, Campbell, CA, USA) is a small, lightweight and comfortable patch, which is attached to the chest. The patch is unique in measuring stress continuously and depicting stress real time, using a validated algorithm that computes stress as a combination of HRV and HR.34, 35 Because of these features the patch has potential to be used in training situations and to assess chronic stress.
An exploratory study was conducted determining the value of the patch in continuously measuring stress levels in surgeons and surgical residents during all work activities in comparison to usual self perceived stress scoring. Important objective was to evaluate to what extent demographic and surgical factors, surgical experience level in particular, affect this stress.
Section snippets
Participants
Consultants, fellows and residents were recruited from the surgical department of the Radboud university medical center in the Netherlands between July 2014 and December 2014. A sample size calculation was not deemed necessary because of the exploratory nature of this study. Demographics including gender, age, level of surgical experience and concurrent use of medication affecting heart rate were noted. Participants gave verbal consent after being informed about the study and the anonymous
Results
Five consultants, seven fellows and senior residents, and eight junior residents (11 men and 9 women) participated. The mean age (±SD) of the consultants, fellows and senior residents, and junior residents were respectively 46.20 (±7.16) years, 35.43 (±4.44) years, 32.25 (±1.83) years. The mean (±SD) years of experience at consultant level was 11.80 (±6.91) years. At the time of data collection, one fellow and one junior resident were pregnant for six weeks. One male fellow used beta-blockers.
Discussion
Continuous stress monitoring in surgeons and surgical residents using a new, small and light weighted, wearable sensor patch reveals relevant and almost complete data on stress levels of surgeons and residents during their workday. Performing an operation was more stressful than other daily activities, particularly for fellows and residents, and based on different stress calculations. The patch did not interfere with the activities and was well tolerated by most participants, and measured
Conclusion
Continuous stress monitoring in surgeons and residents using a simple, easy to wear sensor patch reveals real time data on different stress levels of surgeons and residents during the day. With this new technique we could demonstrate that performing an operation is more stressful than other daily activities in the hospital, particularly with less surgical experience. The stress percentage allows for real time feedback of the stress level making the sensor patch suitable for a widespread
Funding sources
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Acknowledgments
We gratefully acknowledge Mr. Mats Koeneman (MSc) for his technical support and proof reading the manuscript.
References (51)
- et al.
What about the surgeon?
Int J Surg
(2013) - et al.
Beyond the body: a systematic review of the nonphysical effects of a surgical career
Surgery
(2016) - et al.
Burnout among American surgeons
Surgery
(2001) - et al.
Changes in mental health of UK hospital consultants since the mid-1990s
Lancet
(2005) - et al.
The cardiovascular toll of stress
Lancet
(2007) - et al.
Meta-analysis of perceived stress and its association with incident coronary heart disease
Am J Cardiol
(2012) - et al.
The effects of stress on surgical performance
Am J Surg
(2006) - et al.
Factors compromising safety in surgery: stressful events in the operating room
Am J Surg
(2010) - et al.
What stress coping strategies are surgeons relying upon during surgery?
Am J Surg
(2015) - et al.
Managing intraoperative stress: what do surgeons want from a crisis training program?
Am J Surg
(2009)
A prospective study of patient safety in the operating room
Surgery
Analysis of surgical errors in closed malpractice claims at 4 liability insurers
Surgery
Analysis of errors reported by surgeons at three teaching hospitals
Surgery
Psychophysiological biomarkers of workplace stressors
Neurosci Biobehav R
A prospective study of heart rate variability in endocrine surgery: surgical training increases consultant's mental strain
J Surg Educ
Improvements in heart rate variability with exercise therapy
Can J Cardiol
Hair cortisol as a biological marker of chronic stress: current status, future directions and unanswered questions
Psychoneuroendocrinology
Hair cortisol: a new tool for evaluating stress in programs of stress management
Life Sci
Stress and burnout among surgeons: understanding and managing the syndrome and avoiding the adverse consequences
Arch Surg
Stress and cardiovascular disease: an update on current knowledge
Annu Rev Publ Health
Work-related psychosocial factors and the development of ischemic heart disease: a systematic review
Cardiol Rev
Negative stress-coping strategies among novices in surgery correlate with poor virtual laparoscopic performance
Br J Surg
Stress impairs psychomotor performance in novice laparoscopic surgeons
Surg Endosc
The impact of stress on surgical performance: a systematic review of the literature
Surgery
The effect of stress-inducing conditions on the performance of a laparoscopic task
Surg Endosc
Cited by (43)
Extended-Duration Work Shifts in Surgical Specialties: A Systematic Review
2024, Journal of Surgical ResearchWearable sensor for psychological stress monitoring of pregnant woman – State of the art
2023, Measurement: Journal of the International Measurement ConfederationPreparatory surgical bootcamp: An effective form of training with a positive impact on self-confidence and procedural skills of the residents
2022, Surgery in Practice and SciencePsychological and physiological effects of a green wall on occupants: A cross-over study in virtual reality
2021, Building and EnvironmentCitation Excerpt :In this study, this software was used to determine applicable indices, such as the standard deviation of the normal-to-normal interval (SDNN) and the root mean square of the successive differences (RMSSD), to analyze the stress level and the activity of the autonomous nervous system of the subject. The low frequency/high frequency (LF/HF) ratio, one of the most widely used indices in HRV analysis, is more sensitive to noise waves and has low reliability in a short measurement duration, so it was not included in the analysis [45,46]. Below are the detailed explanations of SDNN and RMSSD.
Measurement of Trauma Caregiver Stress: Validation of HRV in a Real-World Surgical Setting
2021, Journal of Surgical ResearchCitation Excerpt :HRV devices can be worn on many sites, including the arm, chest and wrist. Changes can be detected as frequently as every 3 s, allowing real-time monitoring.11 Widespread adoption of HRV has been complicated by the myriad options used by different authors for data analysis and selection of a specific HRV metric.
Applying augmented reality in teaching of surgical residents—telementoring, a “stress-free” way to surgical autonomy?
2024, Langenbeck's Archives of Surgery