Debra Nestel

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

BACKGROUNDnSafe 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.nnnMETHODSnA 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.nnnRESULTSnIn 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).nnnCONCLUSIONnSurgeons 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.

An innovative model for teaching and learning clinical procedures

Contextu2002 Performing a clinical procedure requires the integration of technical clinical skills with effective communication skills. However, these skills are often taught separately.

Role-play for medical students learning about communication: Guidelines for maximising benefits

BackgroundRole-play is widely used as an educational method for learning about communication in medical education. Although educational theory provides a sound rationale for using this form of simulation, there is little published evidence for its effectiveness. Students prior experiences of role-play may influence the way in which they engage in this method. This paper explores students experiences with the aim of producing guidelines for maximising the benefits of role-play within this learning context.MethodsFirst-year undergraduate medical students participated in a role-play session as part of their communication programme. Before and after the session, students completed questionnaires. In the pre-session questionnaire, students were asked about their experiences of role-play and asked to identify helpful and unhelpful elements. Immediately after the session, students answered similar questions in relation to the role-play activity they had just completed. Descriptive statistics were used to analyse quantitative data and qualitative data was thematically analysed.Results284 students completed evaluation forms. Although 63 (22.2%) had prior unhelpful experiences, most students (n = 274; 96.5%) found this experience helpful. Summary findings were that students reported the key aspects of helpful role-play were opportunities for observation, rehearsal and discussion, realistic roles and alignment of roles with other aspects of the curriculum. Unhelpful aspects were those that evoked strong negative emotional responses and factors that contributed to a lack of realism.ConclusionRole-play was valued by students in the acquisition of communication skills even though some had prior unhelpful experiences. Guidelines for effective role-play include adequate preparation, alignment of roles and tasks with level of practice, structured feedback guidelines and acknowledgment of the importance of social interactions for learning.

Complexity, risk and simulation in learning procedural skills

Backgroundu2002 A complex chain of events underpins every clinical intervention, especially those involving invasive procedures. Safety requires high levels of awareness and vigilance. In this paper we propose a structured approach to procedural training, mapping each learners evolving experience within a matrix of clinical risk and procedural complexity. We use a traffic light analogy to conceptualise a dynamic awareness of prevailing risk and the implications of moving between zones.

Assessing procedural skills in context: exploring the feasibility of an Integrated Procedural Performance Instrument (IPPI)

Backgroundu2002 The assessment of clinical procedural skills has traditionally focused on technical elements alone. However, in real practice, clinicians are expected to be able to integrate technical with communication and other professional skills. We describe an integrated procedural performance instrument (IPPI), where clinicians are assessed on 12 clinical procedures in a simulated clinical setting which combines simulated patients (SPs) with inanimate models or items of medical equipment. Candidates are observed remotely by assessors whose data are fed back to the clinician within 24u2003hours of the assessment. This paper describes the feasibility of IPPI.

Factors compromising safety in surgery: stressful events in the operating room

BACKGROUNDnStressful events occur in the operating room (OR) with potentially severe consequences for patient safety. We recorded the incidence of these events in the OR, assessed the levels of stress that they caused, and investigated their detectability.nnnMETHODSnStressful incidents in the OR were recorded and rated in real time by an observer in 55 general and orthopedic procedures. Operating surgeons also rated incident stressfulness and their stress (validated State Trait Anxiety Inventory).nnnRESULTSnThe total count of stressors/case ranged from 1 to 23.5 (mean, 5.87). Technical, patient, and equipment problems occurred frequently and were most stressful. Frequent but least severe stressors were distractions/interruptions, whereas least frequent/most severe stressors were teamwork problems. These events were associated with an increase in surgeons self-reported stress. The observer was able to capture surgeons stress accurately.nnnCONCLUSIONSnSystematically occurring stressors in the OR affect surgeons and can be assessed accurately. Further research should investigate the impact of stress on surgical performance.

Distributed simulation--accessible immersive training.

Distributed simulation (DS) is the concept of high-fidelity immersive simulation on-demand, made widely available wherever and whenever it is required. DS provides an easily transportable, self-contained ‘set’ for creating simulated environments within an inflatable enclosure, at a small fraction of the cost of dedicated, static simulation facilities. High-fidelity simulation is currently confined to a relatively small number of specialised centres. This is largely because full-immersion simulation is perceived to require static, dedicated and sophisticated equipment, supported by expert faculty. Alternatives are needed for healthcare professionals who cannot access such centres. We propose that elements of immersive simulations can be provided within a lightweight, low-cost and self-contained setting which is portable and can therefore be accessed by a wide range of clinicians. We will argue that mobile simulated environments can be taken to where they are needed, making simulation more widely available. We develop the notion that a simulation environment need not be a fixed, static resource, but rather a ‘container’ for a range of activities and performances, designed around the needs of individual users. We critically examine the potential of DS to widen access to an otherwise limited resource, putting flexible, ‘just in time’ training within reach of all clinicians. Finally, we frame DS as a ‘disruptive innovation’ with potential to radically alter the landscape of simulation-based training.

Managing intraoperative stress: what do surgeons want from a crisis training program?

BACKGROUNDnCurrent surgical training provides little opportunity for surgeons to recognize and manage intraoperative stress before it affects performance and compromises patient safety. We explored the perceived need for structured stress training and propose an intervention design that may be acceptable and appropriate.nnnMETHODSnFifteen semistructured interviews identified stressors in the operating room, characterized coping strategies, and explored surgeons views about a training intervention. Interviews were analyzed using standard qualitative methods.nnnRESULTSnStressors and coping strategies confirmed those identified in previous work. Key components of an intervention should include recognizing stress in oneself and in others; experiencing the impact of stress on performance; providing effective coping strategies; offering feedback; and providing opportunities to practice what has been taught in a safe, simulation-based environment.nnnCONCLUSIONSnThere is a need for structured training in management of intraoperative stress. Surgeons would welcome a simulation-based intervention to enhance performance and patient safety.

Blurring the boundaries: scenario-based simulation in a clinical setting

Contextu2002 The ability to perform clinical procedures safely is a key skill for health care professionals. Performing such procedures on conscious patients is challenging and requires a combination of technical and communication skills. We have developed quasi‐clinical scenarios, where inanimate models attached to simulated patients provide a convincing learning environment. Procedures are rated by expert observers and by the ‘patient’ and recorded for subsequent review. This study explores the potential of locating such scenarios within a real clinical setting, allowing participants to experience the challenges of the workplace while ensuring patient safety. An innovative portable digital recording device (the ‘Virtual Chaperone’) is evaluated for use in clinical settings.

Nurses' perceptions and experiences of communication in the operating theatre: a focus group interview

Nurses perceptions and experiences of communication in the operating theatre: a focus group interviewBackgroundCommunication programmes are well established in nurse education. The focus of programmes is most often on communicating with patients with less attention paid to inter-professional communication or skills essential for working in specialised settings. Although there are many anecdotal reports of communication within the operating theatre, there are few empirical studies. This paper explores communication behaviours for effective practice in the operating theatre as perceived by nurses and serves as a basis for developing training.MethodsA focus group interview was conducted with seven experienced theatre nurses from a large London teaching hospital. The interview explored their perceptions of the key as well as unique features of effective communication skills in the operating theatre. Data was transcribed and thematically analysed until agreement was achieved by the two authors.ResultsThere was largely consensus on the skills deemed necessary for effective practice including listening, clarity of speech and being polite. Significant influences on the nature of communication included conflict in role perception and organisational issues. Nurses were often expected to work outside of their role which either directly or indirectly created barriers for effective communication. Perceptions of a lack of collaborative team effort also influenced communication.ConclusionAlthough fundamental communication skills were identified for effective practice in the operating theatre, there were significant barriers to their use because of confusion over clarity of roles (especially nurses roles) and the implications for teamwork. Nurses were dissatisfied with several aspects of communication. Future studies should explore the breadth and depth of this dissatisfaction in other operating theatres, its impact on morale and importantly on patient safety. Interprofessional communication training for operating theatre staff based in part on the key issues identified in this study may help to create clarity in roles and focus attention on effective teamwork and promote clinical safety.