title: Increased stress levels may explain the incomplete transfer of simulator-acquired skill to the operating room.
abstract: BACKGROUND
  Proficiency-based simulator training in laparoscopic suturing leads to improved operative performance, but the skill transfer is incomplete. The objective of this study was to examine the stress level of trainees during the transition from the simulator to the operating room (OR) and its impact on performance.
  
  
  METHODS
  Novices (n = 20) were randomized into training and control groups. After the training group achieved proficiency in laparoscopic suturing, both groups were tested on a live porcine, laparoscopic Nissen fundoplication model. Participant performance was assessed using an objective score. Stress level was evaluated by recording beat-to-beat heart rate (BBHR) and short-term heart rate variability (STHRV) at baseline, after achieving proficiency (only the training group) and in the OR. Repeated measurement analysis of variance (ANOVA) and t test were used for analysis.
  
  
  RESULTS
  Baseline simulator performance and data for heart rate variability were similar for both groups. After achieving simulator proficiency, the trained group demonstrated the anticipated decrease in performance (mean average + or - SEM) in the OR (524 + or - 17 vs 290 + or - 95; P < .001), and an increase in BBHR (98 + or - 14 vs115 + or - 18; P < .001) but not STHRV (4.1 + or - 0.8 vs 3.7 + or - 0.9; P = .5). A similar but lesser increase of the BBHR was observed in the control group compared to the study group.
  
  
  CONCLUSIONS
  BBHR was a more sensitive measure of stress level compared with STHRV. The increased BBHR observed in the OR that reflects stress and performance anxiety may explain the incomplete transfer of simulator-acquired skill in novice learners.
authors.affiliation: Division of Gastrointestinal and Minimally Invasive Surgery, Carolinas Medical Center, 1000 Blythe Boulevard, MEB 601, Charlotte, NC 28203, USA.
authors.forename: Ajita
authors.initials: A
authors.lastname: Prabhu
authors.forename: Warren
authors.initials: W
authors.lastname: Smith
authors.forename: Yuliya
authors.initials: Y
authors.lastname: Yurko
authors.forename: Christina
authors.initials: C
authors.lastname: Acker
authors.forename: Dimitrios
authors.initials: D
authors.lastname: Stefanidis
mesh_terms: D000328:Adult; D000818:Animals; D003162:Competency-Based Education / Q000379:methods*; D003194:Computer-Assisted Instruction / Q000379:methods*; D004516:Education, Premedical / Q000379:methods*; D005260:Female; D018662:Fundoplication / Q000193:education; D013502:General Surgery / Q000193:education*; D006801:Humans; D010535:Laparoscopy; D008297:Male; D023421:Models, Animal; D009873:Operating Rooms; D013315:Stress, Psychological / Q000523:psychology*; D013340:Students, Premedical / Q000523:psychology*; D013552:Swine; D055815:Young Adult