Elsevier

Surgery

Volume 147, Issue 3, March 2010, Pages 318-330.e6
Surgery

Original Communication
The impact of stress on surgical performance: A systematic review of the literature

https://doi.org/10.1016/j.surg.2009.10.007Get rights and content

Background

Safe surgical practice requires a combination of technical and nontechnical abilities. Both sets of skills can be impaired by intra-operative stress, compromising performance and patient safety. This systematic review aims to assess the effects of intra-operative stress on surgical performance.

Methods

A systematic search strategy was implemented to obtain relevant articles. MEDLINE, EMBASE, and PsycINFO databases were searched, and 3,547 abstracts were identified. After application of limits, 660 abstracts were retrieved for subsequent evaluation. Studies were included on the basis of predetermined inclusion criteria and independent assessment by 2 reviewers.

Results

In all, 22 articles formed the evidence base for this review. Key stressors included laparoscopic surgery (7 studies), bleeding (4 studies), distractions (4 studies), time pressure (3 studies), procedural complexity (3 studies), and equipment problems (2 studies). The methods for assessing stress and performance varied greatly across studies, rendering cross-study comparisons difficult. With only 7 studies assessing stress and surgical performance concurrently, establishing a direct link was challenging. Despite this shortfall, the direction of the evidence suggested that excessive stress impairs performance. Specifically, laparoscopic procedures trigger greater stress levels and poorer technical performance (3 studies), and expert surgeons experience less stress and less impaired performance compared with juniors (2 studies). Finally, 3 studies suggest that stressful crises impair surgeons' nontechnical skills (eg, communication and decision making).

Conclusion

Surgeons are subject to many intra-operative stressors that can impair their performance. Current evidence is characterized by marked heterogeneity of research designs and variable study quality. Further research on stress and performance is required so that surgical training and clinical excellence can flourish.

Section snippets

Aims

This article aims to review the literature on stress and intra-operative performance systematically, drawing on evidence from surgery, psychology, and human factors research. It addresses the following questions:

  • 1.

    What are the key stressors that affect surgeons in the operative environment?

  • 2.

    What methods/tools are used to measure acute stress in surgery?

  • 3.

    What are the effects of stress on surgical performance?

Search strategy

Databases searched included MEDLINE (1965–April 2008), PsycINFO (1967–April 2008), EMBASE (1980–April 2008), and the Central Cochrane Register of Clinical Trials (issue 4, 2005) for trials indexed in 2004. In addition, the “gray literature” was searched to include conference proceedings. The search was triangulated by reviewing the reference lists of all retrieved relevant articles for additional articles. All retrieved articles were reviewed by 1 of the reviewers (S.A.) who screened the titles

Selected articles

The search yielded 3,547 citations, of which 2,887 articles were excluded after limits were applied. During the process of study selection, 619 of the remaining 660 abstracts did not fit the inclusion criteria and were excluded. Of the remaining 41 articles, 13 were removed because of duplicate publication across different databases. The full texts of the remaining 28 articles were evaluated in detail, and another 6 articles were eliminated as not meeting our inclusion criteria. This left a

Discussion

The decision to operate is made after balancing the risks and benefits for the patient. The level of stress experienced by the surgeon is seldom factored in as a potential contributor to outcome, although it is intuitive that excessive levels of stress can affect performance adversely—especially for novice surgeons. This review aimed to identify key stressors, capture methods for measuring intraoperative stress, and gauge the impact of stress on surgical performance. Clearly, the evidence base

References (58)

  • W.H. Bunch et al.

    The stresses of the surgical residency

    J Surg Res

    (1992)
  • N. Sevdalis et al.

    Reliability of a revised NOTECHS scale for use in surgical teams

    Am J Surg

    (2008)
  • C. Vincent et al.

    Systems approaches to surgical quality and safety: from concept to measurement

    Ann Surg

    (2004)
  • J.F. Calland et al.

    A systems approach to surgical safety

    Surg Endosc

    (2002)
  • R. Aggarwal et al.

    Laparoscopic skills training and assessment

    Br J Surg

    (2004)
  • R. Kneebone

    The human face of simulation: patient-focused simulation training

    Acad Med

    (2006)
  • S. Undre et al.

    Teamwork in the operating theatre: cohesion or confusion?

    J Eval Clin Pract

    (2006)
  • H. Selye

    The evolution of the stress concept

    Am Scientist

    (1973)
  • R.M. Yerkes et al.

    The relation of strength of stimulus to rapidity of habit formation

    J Comp Neurol Psychol

    (1908)
  • R.S. Lazarus

    The psychology of stress and coping

    Issues Ment Health Nurs

    (1985)
  • N. Sevdalis et al.

    Annoyances, disruptions, and interruptions in surgery: the Disruptions in Surgery Index (DiSI)

    World J Surg

    (2008)
  • N. Sevdalis et al.

    Distracting communications in the operating theatre

    J Eval Clin Pract

    (2007)
  • D.A. Campbell et al.

    Burnout among American surgeons

    Surgery

    (2001)
  • R. Berguer et al.

    Performing laparoscopic surgery is significantly more stressful for the surgeon than open surgery

    Surg Endosc

    (2001)
  • W.D. Smith et al.

    A virtual instrument ergonomics workstation for measuring the mental workload of performing video-endoscopic surgery

    Stud Health Technol Inform

    (2000)
  • (2005)
  • I. Hassan et al.

    Negative stress-coping strategies among novices in surgery correlate with poor virtual laparoscopic performance

    Br J Surg

    (2006)
  • J.E. Driskell et al.

    Overcoming the effects of stress on military performance; human factors, training and selection strategies

    (1991)
  • R. Flin et al.

    Safety at the sharp end: a guide to non-technical skills

    (2008)
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