The Imperial Stress Assessment Tool (ISAT): a feasible, reliable and valid approach to measuring stress in the operating room.
BACKGROUND
Stress can impair surgical performance and may compromise patient safety. This prospective, cross-sectional study describes the feasibility, reliability, and validity of the Imperial Stress Assessment Tool (ISAT) as an approach to measuring stress during surgery.


METHODS
A total of 54 procedures were observed with 11 surgeons (4 attendings, 4 senior residents and 3 junior residents) in a large university teaching hospital in London, UK. Data collection involved physiological measures of operating surgeons [heart rate (HR) and salivary cortisol] and self-report questionnaires (State Trait Anxiety Inventory, or STAI).


RESULTS
In all, 23 of 54 procedures were stressful, as identified by self-reporting. For stressful procedures compared to nonstressful ones, STAI was higher (mean +/- SD) 9.81 +/- 2.20 vs. 12.87 +/- 4.27, t (30.64) = 3.15 as was the HR (mean +/- SD) 79.94 +/- 8.55 vs. 93.17 +/- 14.94, t(32.57) = 3.81) (p < 0.05). Significant positive correlations were obtained between the measures indicating concurrent validity: Pearson's r = 0.47 (HR vs. STAI), 0.34 (cortisol vs. STAI), and 0.57 (HR vs. cortisol) (p < 0.05). Perfect correlation of subjective and objective measures was found for 70% of the procedures. HR and cortisol had specificities of 78% and 91% and sensitivities of 91% and 70% respectively for detecting stress during surgery.


CONCLUSIONS
ISAT is a nonintrusive, feasible approach that combines subjective and objective methods for measuring stress in the operating room. The ISAT may increase understanding of the effects of stress on clinical performance and outcomes, leading to improved patient care.
Arora
Sonal
S
Department of Biosurgery and Surgical Technology, Imperial College, 10th Floor QEQM Building, Praed Street, London, W2 1NY, UK. Sonal.Arora06@imperial.ac.uk
Tierney
Tanya
T
Sevdalis
Nick
N
Aggarwal
Rajesh
R
Nestel
Debra
D
Woloshynowych
Maria
M
Darzi
Ara
A
Kneebone
Roger
R
D000328:Adult; D000368:Aged; D002983:Clinical Competence; D003430:Cross-Sectional Studies; D017558:Elective Surgical Procedures / Q000523:psychology / Q000592:standards*; D005240:Feasibility Studies; D005260:Female; D006339:Heart Rate / Q000502:physiology*; D006801:Humans; D006854:Hydrocortisone / Q000032:analysis*; D008131:London / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D009873:Operating Rooms; D010820:Physicians / Q000523:psychology*; D010818:Practice Patterns, Physicians'; D015995:Prevalence; D011446:Prospective Studies; D015203:Reproducibility of Results; D018570:Risk Assessment / Q000379:methods*; D017751:Safety Management; D012463:Saliva / Q000737:chemistry*; D012680:Sensitivity and Specificity; D013315:Stress, Psychological / Q000175:diagnosis* / Q000453:epidemiology; D011795:Surveys and Questionnaires; D016526:Workload / Q000523:psychology
D006854:Hydrocortisone
Surgery. 2010 Mar;147(3):318-30, 330.e1-6
20004924
J Clin Endocrinol Metab. 1988 Feb;66(2):343-8
2828410
Surg Endosc. 2003 Sep;17(9):1481-4
12820061
Am J Surg. 2006 Jan;191(1):5-10
16399098
World J Surg. 2008 Aug;32(8):1643-50
18491185
Am J Surg. 2009 Apr;197(4):537-43
19246024
Eur J Surg. 2002;168(3):139-44
12182237
Stud Health Technol Inform. 1999;62:49-54
10538398
Am J Surg. 2008 Aug;196(2):184-90
18558392
Stud Health Technol Inform. 2005;111:498-501
15718786
J Psychosom Res. 1986;30(4):411-20
3761226
Br J Surg. 2006 Dec;93(12):1554-9
17054315
J Hypertens Suppl. 1989 Dec;7(6):S14-5
2632695
Surgery. 2003 Jun;133(6):614-21
12796727
J Am Coll Surg. 2007 Apr;204(4):697-705
17382230
Am J Surg. 2010 Jan;199(1):60-5
20103067
Biol Psychiatry. 2002 Aug 15;52(4):318-27
12208639
Br J Clin Psychol. 1992 Sep;31(3):301-6
1393159
Surg Endosc. 2008 May;22(5):1263-7
17943357
Ergonomics. 1983 Aug;26(8):803-7
6628358
Issues Ment Health Nurs. 1985;7(1-4):399-418
3854019
Anesthesiology. 1998 Jul;89(1):8-18
9667288
Surg Endosc. 2001 Oct;15(10):1204-7
11727101
Ann Surg. 2009 Jun;249(6):1047-51
19474694
Ann Surg. 2004 Apr;239(4):475-82
15024308
Arch Surg. 2004 Nov;139(11):1215-20
15545569
World J Surg. 2007 Jul;31(7):1373-81
17487527