BackgroundThe purpose of the present study was to develop and validate a multidimensional, surgery-specific workload measure (the SURG-TLX), and to determine its utility in providing diagnostic information about the impact of various sources of stress on the perceived demands of trained surgical operators. As a wide range of stressors have been identified for surgeons in the operating room, the current approach of considering stress as a unidimensional construct may not only limit the degree to which underlying mechanisms may be understood but also the degree to which training interventions may be successfully matched to particular sources of stress.MethodsThe dimensions of the SURG-TLX were based on two current multidimensional workload measures and developed via focus group discussion. The six dimensions were defined as mental demands, physical demands, temporal demands, task complexity, situational stress, and distractions. Thirty novices were trained on the Fundamentals of Laparoscopic Surgery (FLS) peg transfer task and then completed the task under various conditions designed to manipulate the degree and source of stress experienced: task novelty, physical fatigue, time pressure, evaluation apprehension, multitasking, and distraction.ResultsThe results were supportive of the discriminant sensitivity of the SURG-TLX to different sources of stress. The sub-factors loaded on the relevant stressors as hypothesized, although the evaluation pressure manipulation was not strong enough to cause a significant rise in situational stress.ConclusionsThe present study provides support for the validity of the SURG-TLX instrument and also highlights the importance of considering how different stressors may load surgeons. Implications for categorizing the difficulty of certain procedures, the implementation of new technology in the operating room (man–machine interface issues), and the targeting of stress training strategies to the sources of demand are discussed. Modifications to the scale to enhance clinical utility are also suggested.

We conducted two experiments to assess the effect attentional focus has on learning a complex motor skill and subsequent performance under secondary task loading. Participants in Experiment 1 learnt a golf putting task (300 practice trials) with a single instruction to either focus on their hands (internal focus) or the movement of the putter (external focus). No group differences were evident during learning or retention. Differences between the groups were only apparent under secondary task load; the external group's performance remained robust, while the internal group suffered a drop in performance. Verbal protocols demonstrated that the internal group accumulated significantly more internal knowledge and more task-relevant knowledge in general than the external group. Experiment 2 was designed to establish whether greater internal focus knowledge or greater explicit rule build up in general was responsible for performance breakdown. Two groups were presented with a set of six internal or external rules. Again, no performance differences were found during learning or retention. During the secondary task, both groups experienced performance deterioration. It was concluded that accumulation of explicit rules to guide performance was responsible for the internal group's breakdown in performance under secondary task loading and may be responsible for some of the performance differences reported previously.

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