title: The effects of stress and coping on surgical performance during simulations.
abstract: OBJECTIVE
  This study investigates the effects of surgeons' stress levels and coping strategies on surgical performance during simulated operations.
  
  
  METHODS
  Thirty surgeons carried out each a non-crisis and a crisis scenario of a simulated operation. Surgeons' stress levels were assessed by several measures: self-assessments and observer ratings of stress, heart rate, heart rate variability, and salivary cortisol. Coping strategies were explored qualitatively and quantified to a coping score. Experience in surgery was included as an additional predictor. Outcome measures consisted of technical surgical skills using Objective Structured Assessment of Technical Skill (OSATS), nontechnical surgical skills using Observational Teamwork Assessment for Surgery (OTAS), and the quality of the operative end product using End Product Assessment (EPA). Uni- and multivariate linear regression were used to assess the independent effects of predictor variables on each performance measure.
  
  
  RESULTS
  During the non-crisis simulation, a high coping score and experience significantly enhanced EPA (beta1, 0.279; 0.009-0.460; P= 0.04; beta2, 0.571; 4.328-12.669, P< 0.001; respectively). During the crisis simulation, a significant beneficial effect of the interaction of high experience and low stress on all performance measures was found (EPA: beta, 0.537; 2.079-8.543; OSATS: beta, 0.707; 8.708-17.860; OTAS: beta, 0.654; 13.090-30.483; P< 0.01). Coping significantly enhanced nontechnical skills (beta, 0.302; 0.117-1.624, P= 0.03).
  
  
  CONCLUSIONS
  Clinicians' stress and coping influenced surgical performance during simulated operations. Hence, these are critical factors for the quality of health care.
authors.affiliation: Department of Biosurgery, Imperial College London, London, United Kingdom.
authors.forename: Cordula M
authors.initials: CM
authors.lastname: Wetzel
authors.forename: Stephen A
authors.initials: SA
authors.lastname: Black
authors.forename: George B
authors.initials: GB
authors.lastname: Hanna
authors.forename: Thanos
authors.initials: T
authors.lastname: Athanasiou
authors.forename: Roger L
authors.initials: RL
authors.lastname: Kneebone
authors.forename: Debra
authors.initials: D
authors.lastname: Nestel
authors.forename: John H N
authors.initials: JH
authors.lastname: Wolfe
authors.forename: Maria
authors.initials: M
authors.lastname: Woloshynowych
mesh_terms: D000223:Adaptation, Psychological; D000328:Adult; D002983:Clinical Competence; D004630:Emergencies / Q000523:psychology; D016894:Endarterectomy, Carotid / Q000523:psychology*; D005260:Female; D006339:Heart Rate; D006801:Humans; D006854:Hydrocortisone / Q000032:analysis; D007431:Intraoperative Complications / Q000523:psychology; D008297:Male; D016544:Patient Simulation; D012463:Saliva / Q000737:chemistry; D013315:Stress, Psychological / Q000175:diagnosis* / Q000209:etiology; D011795:Surveys and Questionnaires; D055815:Young Adult
chemical_list: D006854:Hydrocortisone