Stress in surgical educational environments: a systematic review

Abstract

Background The effects of stress on surgical residents and how stress management training can prepare residents to effectively manage stressful situations is a relevant topic. This systematic review aimed to analyze the literature regarding (1) the current stress monitoring tools and their use in surgical environments, (2) the current methods in surgical stress management training, and (3) how stress affects surgical performance. Methods A search strategy was implemented to retrieve relevant articles from Web of Science, Scopus, and PubMed. The 787 initially retrieved articles were reviewed for further evaluation according to the inclusion/exclusion criteria (Prospero registration number CRD42021252682). Results Sixty-one articles were included in the review. The stress monitoring methods found in the articles showed heart rate analysis as the most used monitoring tool for physiological parameters while the STAI-6 scale was preferred for psychological parameters. The stress management methods found in the articles were mental-, simulation- and feedback-based training, with the mental-based training showing clear positive effects on participants. The studies analyzing the effects of stress on surgical performance showed both negative and positive effects on technical and non-technical performance. Conclusions The impact of stress responses presents an important factor in surgical environments, affecting residents’ training and performance. This study identified the main methods used for monitoring stress parameters in surgical educational environments. The applied surgical stress management training methods were diverse and demonstrated positive effects on surgeons’ stress levels and performance. There were negative and positive effects of stress on surgical performance, although a collective pattern on their effects was not clear.

Surgeon reported measures of stress and anxiety prior to and after elective gynecological surgery

“…These findings add to early small cohort studies reporting differences in stress based on 7‐point Likert scale 28,29 the DSSQ; 30–32 however, this current study demonstrates feasibility to assess differences in perceived stress between types of surgery in a live surgical environment. In addition, no differences between primary and assistant surgeons nor differences in levels of training have been described using specific stress scales although STAI has been used to identify differences in surgeon training 8,33 . These self‐reported measures stress observed in this study suggest that prior to any operation, surgeons may have already started considering the possible risks, actions, and adaptations that a given surgery will pose, with surgeons of lesser experience potentially anticipating greater stressors.…”

“… 41 Surgeons' self‐reported measure of stress may also be influenced by their internal ability to respond to stressors. 42 The STAI is less likely to be affected by reporting biases compared to simplified scales as visual analogue scales and Likert scales, which likely contributes its more common usage in surgery; 8 however, it has not been designed to measure stress and clinical relevance, including cutoffs, is one of the difficulties in this area. In addition, the STAI was initially described to report dispositional and transient changes in anxiety.…”

“…[4][5][6] Previous research has attempted to measure surgeon stress through both biological responses and self-reported measures of stress. 7,8 Under research conditions, known stressors can activate the sympathetic-adrenal-medullary axis as well as the hypothalamic-pituitary axis, provoking release of pituitary and adrenal hormones including catecholamines which can then induce physiological changes in the cardiovascular and immune systems. 9,10 Measurable physiological responses including heart rate parameters, cortisol variations, sweat secretion, and immune proteins can be assessed in a surgical setting.…”

“… 15 , 16 , 17 The PROMs previously employed in studies of surgeon stress include Likert and visual analog scales of stress, 18 , 19 the Dundee Stress State Questionnaire, 20 and the Spielberger State Trait Anxiety Inventory (STAI). 21 Whilst the STAI 22 and its 6‐item short form 23 are the most commonly reported PROM in studies of surgeon stress, 8 these inventories were designed and validated as a measure of anxiety rather than stress. Although stress and anxiety share many of the same emotional symptoms, stress is caused by an external threat while anxiety is defined by persistent excessive worries that do not go away even in the absence of a stressor.…”

Operating under the influence: The effect of alcohol on operative performance using a virtual robotic training platform - an experimental comparative cohort study

“…Psychological stress and high cognitive load may negatively impact surgical performance and learning [28][29][30][31]. Laparoscopic virtual reality simulation, possibly closest to robotic simulation in end-user experience, has been shown to carry a measurable degree of cognitive load and psychological stress in trainees.…”