title: The impact of stress on surgical performance: a systematic review of the literature.
abstract: 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).
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Bio-Surgery and Surgical Technology, Imperial College, London, UK. Sonal.Arora06@imperial.ac.uk
authors.forename: Sonal
authors.initials: S
authors.lastname: Arora
authors.forename: Nick
authors.initials: N
authors.lastname: Sevdalis
authors.forename: Debra
authors.initials: D
authors.lastname: Nestel
authors.forename: Maria
authors.initials: M
authors.lastname: Woloshynowych
authors.forename: Ara
authors.initials: A
authors.lastname: Darzi
authors.forename: Roger
authors.initials: R
authors.lastname: Kneebone
mesh_terms: D000223:Adaptation, Psychological; D002983:Clinical Competence; D006801:Humans; D007432:Intraoperative Period; D019300:Medical Errors; D013312:Stress, Physiological; D013315:Stress, Psychological / Q000150:complications*; D013647:Task Performance and Analysis