The effect of stress on learning in surgical skill acquisition

Comparison of the effects of apprenticeship training by sandwich feedback and traditional methods on final-semester operating room technology students' perioperative competence and performance: a randomized, controlled trial

BACKGROUND

Effective feedback is fundamental in clinical education, as it allows trainers to constantly diagnose the trainees' condition, determine their weaknesses, and intervene at proper times. Recently, different feedback-based approaches have been introduced in clinical training; however, the effectiveness of such interventions still needs to be studied extensively, especially in the perioperative field. Therefore, this study sought to compare the effects of apprenticeship training using sandwich feedback and traditional methods on the perioperative competence and performance of Operating Room (OR) technology students.

METHODS

Thirty final-semester undergraduate OR technology students taking the apprenticeship courses were randomly allocated into experimental (n = 15) and control (n = 15) groups through the stratified randomization approach. The students in the experimental group experienced Feedback-Based Learning (FBL) using a sandwich model, and the students in the control group participated in Traditional-Based Training (TBT) in six five-hour sessions weekly for three consecutive weeks. All students completed the Persian version of the Perceived Perioperative Competence Scale-Revised (PPCS-R) on the first and last days of interventions. Also, a blinded rater completed a checklist to evaluate all students' performance via Direct Observation of Procedural Skills (DOPS) on the last intervention day. Besides, the students in the FBL filled out a questionnaire regarding their attitude toward the implemented program.

RESULTS

The mean total score of the PPCS-R was significantly higher in the FBL than in the TBT on the last intervention day (P < 0.001). Additionally, the increase in mean change of PPCS-R total score from the first to last days was significantly more in the FBL (P < 0.001). Likewise, the FBL students had higher DOPS scores than the TBT ones (P < 0.001). Most FBL students also had a good attitude toward the implemented program (n = 8; 53.3%).

CONCLUSION

Apprenticeship training using a sandwich feedback-based approach was superior to the traditional method for enhancing perioperative competence and performance of final-semester OR technology students. Additional studies are required to identify the sustainability of the findings.

Stress responses in surgical trainees during simulation-based training courses in laparoscopy

BACKGROUND

Simulation-based training courses in laparoscopy have become a fundamental part of surgical training programs. Surgical skills in laparoscopy are challenging to master, and training in these skills induces stress responses in trainees. There is limited data on trainees' stress levels, the stress responses related to training on different laparoscopic simulators, and how previous experiences influence trainees' stress response during a course. This study investigates physiologic, endocrine and self-reported stress responses during simulation-based surgical skills training in a course setting.

METHODS

We conducted a prospective observational study of trainees attending basic laparoscopic skills training courses at a national training centre. During the three-day course, participants trained on different laparoscopic simulators: Two box-trainers (the D-box and P.O.P. trainer) and a virtual reality simulator (LAPMentor™). Participants' stress responses were examined through heart rate variability (HRV), saliva cortisol, and the State Trait Anxiety Inventory-6 (STAI-6). The correlation between previous laparoscopic experiences and stress response measurements was explored.

RESULTS

Twenty-four surgical trainees were included in the study. Compared to resting conditions, stress measures were significantly higher during simulation-training activity (the D-box (SDNN = 58.5 ± 23.4; LF/HF-ratio = 4.58 ± 2.71; STAI-6 = 12.3 ± 3.9, P < 0.05), the P.O.P trainer (SDNN = 55.7 ± 7.4; RMSSD = 32.4 ± 17.1; STAI-6 = 12.1 ± 3.9, P < 0.05), and the LAPMentor™ (SDNN = 59.1 ± 18.5; RMSSD = 34.3 ± 19.7; LF/HF-ratio = 4.71 ± 2.64; STAI-6 = 9.9 ± 3.0, P < 0.05)). A significant difference in endocrine stress response was seen for the simulation-training activity on the D-box (saliva cortisol: 3.48 ± 1.92, P < 0.05), however, no significant differences were observed between the three simulators. A moderate correlation between surgical experience, and physiologic and endocrine stress response was observed (RMSSD: r=-0.31; SDNN: r=-0.42; SD2/SD1 ratio: r = 0.29; Saliva cortisol: r = 0.46; P < 0.05), and a negative moderate correlation to self-reported stress (r=-0.42, P < 0.05).

CONCLUSION

Trainees have a significant higher stress response during simulation-training compared to resting conditions, with no difference in stress response between the simulators. Significantly higher cortisol levels were observed on the D-box, indicating that simulation tasks with time pressure stress participants the most. Trainees with more surgical experience are associated with higher physiologic stress measures, but lower self-reported stress scores, demonstrating that surgical experience influences trainees' stress response during simulation-based skills training courses.

A scoping review of emotions and related constructs in simulation-based education research articles

BACKGROUND

While acknowledgement of emotions' importance in simulation-based education is emerging, there are concerns regarding how education researchers understand the concept of emotions for them to deliberately incorporate emotionally charged scenarios into simulation-based education. This concern is highlighted especially in the context of medical education often lacking strong theoretical integration. To map out how current simulation-based education literature conceptualises emotion, we conducted a scoping review on how emotions and closely related constructs (e.g. stress, and emotional intelligence) are conceptualised in simulation-based education articles that feature medical students, residents, and fellows.

METHODS

The scoping review was based on articles published in the last decade identified through database searches (EMBASE and Medline) and hand-searched articles. Data extraction included the constructs featured in the articles, their definitions, instruments used, and the types of emotions captured. Only empirical articles were included (e.g. no review or opinion articles). Data were charted via descriptive analyses.

RESULTS

A total of 141 articles were reviewed. Stress was featured in 88 of the articles, while emotions and emotional intelligence were highlighted in 45 and 34 articles respectively. Conceptualisations of emotions lacked integration of theory. Measurements of emotions mostly relied on self-reports while stress was often measured via physiological and self-report measurements. Negative emotions such as anxiety were sometimes seen as interchangeable with the term stress. No inferences were made about specific emotions of participants from their emotional intelligence.

CONCLUSIONS

Our scoping review illustrates that learners in simulation-based education are most often anxious and fearful. However, this is partially due to medical education prioritising measuring negative emotions. Further theoretical integration when examining emotions and stress may help broaden the scope towards other kinds of emotions and better conceptualisations of their impact. We call for simulation education researchers to reflect on how they understand emotions, and whether their understanding may neglect any specific aspect of affective experiences their simulation participants may have.

Improving surgical skills with feedback: directly-observed versus video-recorded practice

OBJECTIVE

This study aimed to compare two methods of feedback: verbal face-to-face feedback after direct observation (F2F-feedback) versus electronic-written feedback after observation of recorded-VDO of student's performance (VDO-feedback), in terms of effectiveness in improving skill, effects on motivation and satisfaction.

BACKGROUND

Medical schools are responsible for teaching and ensuring proficiency of basic surgical skills. Feedback is effective in developing psychomotor skills; by providing information of learner's current performance, how to improve, and enhancing motivation.

MATERIALS AND METHOD

Fifty-eight medical students (3rd- 4th year) were trained to perform vertical mattress suture in small groups. Then, during 6-week period of self-directed practice, students were randomized into group1 VDO-feedback (male:female = 21:8) and group 2 F2F-feedback (male:female = 20:9). Feedbacks were provided once every 2 weeks (Week2, Week4). End-of-rotation OSCE was at Week6, and retention tested was at Week8. Performance checklist (Cronbach's Alpha 0.72) was used to assess skill at 4 timepoints; pre- and post- small group learning, OSCE, and retention phase. Questionnaire was used to assess motivation, learning strategies and satisfaction (Cronbach's Alpha 0.83).

RESULT

After in-class learning, further significant improvement of skills could be gained by both F2F- and VDO- feedbacks (p < 0.0001). Both could similarly retain skill for at least 4 weeks later without additional practice. Self-efficacy, test anxiety, and cognitive strategies scores were significantly increased in both groups (p < 0.05). Extrinsic motivation was increased in VDO-feedback group. No difference in satisfaction between groups was observed.

DISCUSSION AND CONCLUSION

VDO-feedback could be alternative to F2F-feedbacks for basic surgical skill training when limitation for simultaneous meeting of teacher and students occurs.

TRIAL REGISTRATION

This study has been registered to Thai Clinical Trial Registry (WHO International Clinical Trial Registry Platform) on 11/07/2023 (TCTR20230711005).

A randomized controlled trial of mindfulness-based stress reduction on academic resilience and performance in college students

OBJECTIVE

The transition into college can pose barriers for student success. We examined the impact of mindfulness-based stress reduction (MBSR) compared to an active and no treatment control group, respectively, on stressor appraisals, academic persistence, and performance in unversity students.

PARTICIPANTS

Students were randomly assigned to receive MBSR (n = 29), study skills active control (n = 27), or no treatment (n = 29).

METHOD

Participants reported stressor appraisals and academic persistence pre- and post-intervention. Semester grade point average (GPA) and enrollment was also obtained.

RESULTS

Academic stressor appraisals did not vary by group. MBSR was protective against depleted academic persistence, whereas academic persistence decreased in the control groups. Enrollment rates remained unchanged in the MBSR group, but increased in the active control relative to no treatment. Finally, GPA improved in the MBSR group, but not controls.

CONCLUSIONS

Findings suggest that MBSR confers some benefits for resilience in university students.

Stress in surgical educational environments: a systematic review

BACKGROUND

The effects of stress on surgical residents and how stress management training can prepare residents to effectively manage stressful situations is a relevant topic. This systematic review aimed to analyze the literature regarding (1) the current stress monitoring tools and their use in surgical environments, (2) the current methods in surgical stress management training, and (3) how stress affects surgical performance.

METHODS

A search strategy was implemented to retrieve relevant articles from Web of Science, Scopus, and PubMed. The 787 initially retrieved articles were reviewed for further evaluation according to the inclusion/exclusion criteria (Prospero registration number CRD42021252682).

RESULTS

Sixty-one articles were included in the review. The stress monitoring methods found in the articles showed heart rate analysis as the most used monitoring tool for physiological parameters while the STAI-6 scale was preferred for psychological parameters. The stress management methods found in the articles were mental-, simulation- and feedback-based training, with the mental-based training showing clear positive effects on participants. The studies analyzing the effects of stress on surgical performance showed both negative and positive effects on technical and non-technical performance.

CONCLUSIONS

The impact of stress responses presents an important factor in surgical environments, affecting residents' training and performance. This study identified the main methods used for monitoring stress parameters in surgical educational environments. The applied surgical stress management training methods were diverse and demonstrated positive effects on surgeons' stress levels and performance. There were negative and positive effects of stress on surgical performance, although a collective pattern on their effects was not clear.

Simulation-based skills training: a qualitative interview study exploring surgical trainees' experience of stress

INTRODUCTION

Stress can affect the ability to acquire technical skills. Simulation-based training (SBT) courses allow surgical trainees to train their technical skills away from stressful clinical environments. Trainees' subjective experiences of stress during SBT courses on laparoscopic surgery remains understudied. Here, we explored the subjective stress experiences of surgical trainees during mandatory laparoscopic SBT courses. We aimed to obtain a broader understanding of which factors of the simulation training the trainees perceived as eliciting stress.

METHODS

A qualitative study with semistructured individual interviews was undertaken to explore trainees' subjective experiences of stress. Twenty surgical trainees participated while attending courses at a national training center for advanced laparoscopic surgery. Questions explored trainees' stress experiences during the SBT courses with a focus on perceived stressors related to laparoscopic simulation training on two box-trainers and one virtual reality simulator. Interview data were analyzed using inductive, qualitative content analysis methods to identify codes, categories, and themes.

RESULTS

Findings indicated that trainees have a variety of stress experiences during laparoscopic SBT. Three main themes were identified to be related to stress experiences: simulation task requirements, psychomotor skill levels and internal pressures, with subcategories such as task difficulty and time requirements, unrealistic haptic feedback and realism of graphics, inconsistent and poor technical performance, and self-imposed pressures and socio-evaluative threats.

CONCLUSIONS

Insights into surgical trainees' experience of stress during laparoscopic SBT courses showed that some stress experiences were directly related to simulation training, while others were of psychological nature. The technical and efficiency requirements of simulation tasks elicited stress experiences among trainees with less laparoscopic experience and lower levels of psychomotor skills. Self-imposed pressures played an integral part in how trainees mobilized and performed during the courses, suggesting that levels of stress might enhance laparoscopic simulation performance. For course facilitators aiming at optimizing future laparoscopic SBT courses, attending to the realism, providing clarity about learning objectives, and having awareness of individual differences among trainees' technical level when designing the simulation tasks, would be beneficial. Equally important to the laparoscopic SBT is to create a psychological safe learning space in order to reduce the internal pressures of trainees.

Resilience for Undergraduate Students: Development and Evaluation of a Theory-Driven, Evidence-Based and Learner Centered Digital Resilience Skills Enhancement (RISE) Program

Protective factors that build students' resilience are known. A six-week digital resilience training program was developed on the basis of theory, evidence, and contextual information. The feasibility study sought to evaluate the acceptability, appropriateness, demand, implementation, and limited efficacy of a digital resilience skills enhancement program for undergraduate students. A single group, pre-test, post-test, concurrent mixed methods design among 10 undergraduate students was conducted in one university in Singapore. The content analysis concluded that students accepted and perceived the digital resilience skills enhancement program as appropriate. Students also proposed several improvements, such as the initiation of the program and revisions to the content. The Wilcoxon signed-rank test found significant improvements in resilience (p = 0.02) and meta-cognitive self-regulation (p = 0.01) scores with medium (d = 0.79, 95% CI: -0.15 to 1.74) and very large effect sizes (d = 1.31, 95% CI: 0.30-2.33), respectively. Students found the digital resilience program appropriate and were able to apply their newly acquired skills to promote their resilience and learning. Although, several improvements are proposed to enhance the rigor of the digital resilience program, the findings of this study suggests that digital resilience programs are important for students' well-being.

The effect of an attending versus neutral observer on peg transfer and intracorporeal knot-tying laparoscopic tasks

BACKGROUND

Surgery is an outcome-based specialty where maintaining peak performance is crucial to patient care. There are a variety of identified surgeon stressors that can have an impact on performance, but one factor unique to surgical residents is the observation by an attending surgeon. This study explored how the perceived authority of the observer had an impact on the participants' physiologic markers of stress and task completion times.

METHODS

Eighteen general surgery residents performed the Fundamentals of Laparoscopic Surgery skills intracorporeal knot-tying and peg transfer tasks in a crossover study design while under the observation of an attending and a neutral observer. Heart rate variability, mean R-R interval, the time between R spikes on an EKG, minimum heart rate, maximum heart rate, average heart rate, and time to task completion were recorded. Analyses were completed via 2 × 2 analysis of variance with repeated measures.

RESULTS

When observed by an attending, participants demonstrated higher minimum, average, and maximum heart rates (P = .046, = .007, and < .001, respectively) than when observed by a neutral observer. Attending observation also significantly shortened time to task completion, relative to neutral observation (P = .022).

CONCLUSION

Attending observation is linked to increased objective measures of stress at the time of performance with decreased task completion times. Educational efforts to optimize the response to stress during learning may lead to better outcomes.

Simulation-Based Education of Endovascular Scrub Nurses Reduces Stress and Improves Team Performance

INTRODUCTION

Endovascular procedures have become commonplace in vascular surgery. This development calls for new training strategies for future specialists. Most simulation-based education (SBE) programs have a monodisciplinary focus on physicians, although successful surgery is a multidisciplinary team effort. Mental stress impairs the learning process and surgical performance and heart rate variability (HRV) can be measured as a proxy for both mental and physical stress. This study aims to assess how SBE of endovascular scrub nurses affects team performance and HRV during endovascular aneurysm repair (EVAR).

MATERIALS AND METHODS

Prospective interventional study in which EVAR-inexperienced scrub nurses followed a focused SBE EVAR program. During real-life EVAR procedures, HRV was continuously recorded with a wireless electrocardiogram patch and multidisciplinary team performance was assessed with the Imperial College Error CAPture (ICECAP) tool, before and after the SBE program, allowing each scrub nurse to serve as their own control. Eight scrub nurses with experience in lower limb endovascular procedures, but not EVAR, were invited to participate.

RESULTS

Seven participants completed the study. In five of seven scrub nurses, HRV-derived stress levels during real-time EVAR procedures were lower after SBE compared to before SBE. Mean HRV increased from 24 msec to 35 msec (P < 0.001), indicating stress level reduction. Before SBE, the mean number of errors/hour was 7.3 (standard deviation ± 1.8) compared to 3.6 (standard deviation ± 2.7) after SBE. Most errors were categorized as technical (58 %) and communicative (23 %).

CONCLUSIONS

SBE of scrub nurses may improve team performance and may lower mental stress during EVAR procedures. In this small study, we suggest using mental stress, as evaluated with HRV, and multidisciplinary team performance, as evaluated with ICECAP, to assess SBE effectiveness in real-case EVAR procedures. This SBE program and live ICECAP observations and electrocardiogram patches was well-accepted by scrub nurses and the entire team.

360° 3D virtual reality operative video for the training of residents in neurosurgery

OBJECTIVE

Training of residents is an essential but time-consuming and costly task in the surgical disciplines. During the coronavirus disease 2019 pandemic, surgical education became even more challenging because of the reduced caseload due to the increased shift to corona care. In this context, augmented 360° 3D virtual reality (VR) videos of surgical procedures enable effective off-site training through virtual participation in the surgery. The goal of this study was to establish and evaluate 360° 3D VR operative videos for neurosurgical training.

METHODS

Using a 360° camera, the authors recorded three standard neurosurgical procedures: a lumbar discectomy, brain metastasis resection, and clipping of an aneurysm. Combined with the stereoscopic view of the surgical microscope, 7- to 10-minute 360° 3D VR videos augmented with annotations, overlays, and commentary were created. These videos were then presented to the neurosurgical residents at the authors’ institution using a head-mounted display. Before viewing the videos, the residents were asked to fill out a questionnaire indicating their VR experience and self-assessment of surgical skills regarding the specific procedure. After watching the videos, the residents completed another questionnaire to evaluate their quality and usefulness. The parameters were scaled with a 5-point Likert scale.

RESULTS

Twenty-two residents participated in this study. The mean years of experience of the participants in neurosurgery was 3.2 years, ranging from the 1st through the 7th year of training. Most participants (86.4%) had no or less than 15 minutes of VR experience. The overall quality of the videos was rated good to very good. Immersion, the feeling of being in the operating room, was high, and almost all participants (91%) stated that 360° VR videos provide a useful addition to the neurosurgical training. VR sickness was negligible in the cohort.

CONCLUSIONS

In this study, the authors demonstrated the feasibility and high acceptance of augmented 360° 3D VR videos in neurosurgical training. Augmentation of 360° videos with complementary and interactive content has the potential to effectively support trainees in acquiring conceptual knowledge. Further studies are necessary to investigate the effectiveness of their use in improving surgical skills.

Methods and Measures for Mental Stress Assessment in Surgery: A Systematic Review of 20 Years of Literature

Real-time mental stress monitoring from surgeons and surgical staff in operating rooms may reduce surgical injuries, improve performance and quality of medical care, and accelerate implementation of stress-management strategies. Motivated by the increase in usage of objective and subjective metrics for cognitive monitoring and by the gap in reviews of experimental design setups and data analytics, a systematic review of 71 studies on mental stress and workload measurement in surgical settings, published in 2001-2020, is presented. Almost 61% of selected papers used both objective and subjective measures, followed by 25% that only administered subjective tools - mostly consisting of validated instruments and customized surveys. An overall increase in the total number of publications on intraoperative stress assessment was observed from mid-2010 s along with a momentum in the use of both subjective and real-time objective measures. Cardiac activity, including heart-rate variability metrics, stress hormones, and eye-tracking metrics were the most frequently and electroencephalography (EEG) was the least frequently used objective measures. Around 40% of selected papers collected at least two objective measures, 41% used wearable devices, 23% performed synchronization and annotation, and 76% conducted baseline or multi-point data acquisition. Furthermore, 93% used a variety of statistical techniques, 14% applied regression models, and only one study released a public, anonymized dataset. This review of data modalities, experimental setups, and analysis techniques for intraoperative stress monitoring highlights the initiatives of surgical data science and motivates research on computational techniques for mental and surgical skills assessment and cognition-guided surgery.

Teaching the technical performance of bronchoscopy to residents in a step-wise simulated approach: factors supporting learning and impacts on clinical work - a qualitative analysis

BACKGROUND

The ability to perform a bronchoscopy is a valuable clinical skill for many medical specialities. Learning this skill is demanding for residents, due to the high cognitive load. Lessons learned from cognitive load theory might provide a way to facilitate this learning. The aim of this study was to investigate residents' perception of factors that support and hinder learning, as well as outcome and acceptance of a workshop on flexible bronchoscopy.

METHODS

Three half-day workshops were designed to teach 12 residents the basics of handling a flexible bronchoscope. They consisted of four phases that alternated between short theoretical aspects and longer practical situations. The practical phases focussed initially on manoeuvring a bronchoscope through holes in panels inside a box, and then on examination and practice using a three-dimensional printed model of the bronchial tree. Afterwards, three audio- and video-recorded focus groups were conducted, transcribed and coded, and underwent reflexive thematic analysis.

RESULTS

Analysis of the focus groups defined two themes: (1) factors that supported a safe and positive learning environment were optimised for intrinsic load, simulated setting, absence of pressure, dyad practice (working in pairs), small group sizes and playful learning; and (2) impacts on clinical work were perceived as high levels of learning and improved patient safety. The residents did not report factors that hindered their learning. Some suggestions were made to improve the set-up of the wooden box.

CONCLUSIONS

The half-day workshop was designed according to several factors, including cognitive load theory in a simulated setting, and creation of a safe and positive learning environment. The residents perceived this as supporting learning and patient safety. Further studies can be designed to confirm these results in a quantitative setting.

TRIAL REGISTRATION

This study was not interventional, therefore was not registered.

Stress level experienced by participants in realistic simulation: a systematic review

OBJECTIVES

to identify the available evidence regarding stress levels experienced by participants in education based on a realistic simulation.

METHODS

systematic review that included randomized clinic trials on electronic databases: Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, Latin-American and Caribbean Literature in Health Sciences, LIVIVO, PubMed, Scopus, and Web of Science. The additional search was performed on Google Scholar and OpenGrey. All searches occurred on September 24, 2020. The methodologic quality of the results was evaluated by the Cochrane Collaboration Risk of Bias Tool.

RESULTS

eighteen studies were included, which evaluated the participants' stress using physiologic, self-reported measures, or the combination of both. Stress as experienced in a high level in simulated scenarios.

CONCLUSIONS

evidence of the study included in this systematic review suggest that stress is experienced in a high level in simulated scenarios.

Psychometric Properties and Calibration of the SPOREEM (Students' Perception of the Operating Room Educational Environment Measure)

OBJECTIVE

The experience in the operating room is considered as a crucial element affecting medical students' satisfaction with workplace-based training in surgery. We developed the "Students' Perception of the Operating Room Educational Environment Measure" (SPOREEM) and applied the approach of Item Response Theory to improve accuracy of its measurement.

DESIGN

Psychometric analysis determined the factorial structure. Using Item Response Theory, item thresholds were calculated on response option levels. Sum scores in the factors were then computed using calibrated unit weights.

SETTING

One hundred medical students from the University Medical Center in Goettingen, Germany, enrolled in a one-week surgery rotation completed the SPOREEM.

RESULTS

The final 19-item questionnaire resulted in 3 factors: "Learning support and inclusion" (1), "Workplace atmosphere" (2), and "Experience of emotional stress" (3). Item calibration resulted in refinement of sum scores in the factors. Male students significantly rated factor 1 more positively. Factor 2 was perceived to a similar degree in all 3 surgical disciplines involved. Factor 3 was rated lower by those students planning a surgical field of postgraduate training.

CONCLUSIONS

We developed a valid, reliable, and feasible tool to assess the overall educational climate of undergraduate training in the OR. Calibration of items refined the measurement.

Regularity detection under stress: Faster extraction of probability-based regularities

Acute stress can crucially influence learning and memory processes. One of the key processes underlying human learning and memory is the ability of our brain to rapidly detect and extract regularities from sensory input across time and space leading to effective predictive processing. Here, we aimed to get an in-depth look into the effect of stress on the acquisition of two aspects of regularity extraction. We examined whether and how stress affects the learning (1) of probability-based regularities and (2) of serial order-based regularities in the same experimental design, and (3) the explicit access to the acquired information. Considering that the acquisition of probability-based regularities is a relatively rapid process, we primarily focused on the early phase of the task. We induced stress with the Socially Evaluated Cold Pressor Test in 27 young adults, while 26 participants were enrolled in the control group. Salivary cortisol levels and subjective ratings of affective states showed successful stress induction. After the stress induction, we measured regularity extraction with the cued Alternating Serial Reaction Time task. We found that stress promoted the extraction of probability-based regularities measured by the learning performance in the early phase of the task and did not alter the learning of serial order-based regularities. Post-block reports showed weaker explicit access to the serial order-based regularities in the stress group. Our results can contribute to a process-level understanding on how stress alters learning and memory functions related to predictive processes.

Effect of a behavioral intervention on anxiety and perceived performance of non-technical skills during surgical simulations

BACKGROUND

Surgical trainees experience intrinsic stress and anxiety during high-acuity clinical situations which can negatively impact performance. Emerging data suggests that education in mindfulness-based coping techniques may improve performance. We evaluated the effects of a stress recovery intervention on novice trainees' perceived level of anxiety during an intentionally stressful simulation.

METHODS

Participants were recruited from surgical intern classes over three consecutive years. All participants completed a simulation intentionally designed to evoke a stress response. Participants then completed a stress recovery intervention or received no additional training. All participants then completed a second novel simulation.

RESULTS

Intervention participants had significantly higher self-reported ability to manage stress (intervention 2.4 to 3.6, p < 0.01; control 2.8 to 3.3, p = 0.06), and stop, think, and observe (intervention 2.5 to 3.7, p < 0.01; control 2.6 to 3.3, p = 0.08) during the second simulation. Both groups also had significantly lower levels of state anxiety during the second simulation as compared to the first (intervention 45.1 vs 59.3, p < 0.01; control 49.3 vs 57.4, p < 0.05). During the second simulation, trainees in both groups reported improvements in perceived abilities to: recognize stress (intervention 2.7 to 4.1, p < 0.01; control 2.9 to 3.6, p < 0.05), communicate with and lead their team (intervention 2.4 to 3.3, p < 0.05; control 2.3 to 3.3, p < 0.01), and to prioritize, plan, and prepare (intervention 2.1 to 3.1, p < 0.05; control 2.1 to 3.0, p < 0.01).

CONCLUSION

Our research shows that a brief intervention was associated with a significant increase in trainee ability to both recognize internal stress and engage in proactive coping mechanisms. This research also shows that while repeated stress-inducing simulations may themselves decrease perceived anxiety levels in novice surgical trainees, training in coping strategies may potentiate this effect.

Assessing Application-Based Breastfeeding Education for Physicians and Nurses: A Scoping Review

BACKGROUND

Physicians and nurses are expected to support breastfeeding mothers. However, there is a lack of standardized lactation education throughout training programs and hospitals. As a result, providers lack the necessary confidence and skills to guide mothers throughout the breastfeeding experience. The hands-on nature of breastfeeding management demands the implementation of application-based learning tools to improve skills retention and patient breastfeeding outcomes.

RESEARCH AIM

In this scoping review, we aimed to critically assess the types of application-based breastfeeding management learning tools reported within medical and nursing professions and the evaluation methods of learner and patient outcomes.

METHODS

The authors searched the literature to identify peer-reviewed articles published between 2000 and 2018 with medical or nursing students, residents, or professionals as the target learner group in an application-based educational intervention. Both authors independently assessed the content in the resulting articles, with specific focus on teaching methods, curricular development, and the learning outcomes reported within each study.

RESULTS

Ten articles matched the inclusion criteria and were included in the final review, including five studies from the medical field and five from the field of nursing. Use of real patients was a common method for application-based skills training, followed by role playing and use of standardized patients. Teaching and evaluation methods varied widely across the studies.

CONCLUSION

The results align with existing literature in finding a dearth of high-quality studies assessing breastfeeding education among physicians and nurses. The variability in teaching and evaluation methods indicates a lack of standardization in breastfeeding education between institutions.

Intraoperative Microvascular Complications in Autologous Breast Reconstruction: The Effects of Resident Training on Microsurgical Outcomes

BACKGROUND

 Academic medical centers with large volumes of autologous breast reconstruction afford residents hand-on educational experience in microsurgical techniques. We present our experience with autologous reconstruction (deep inferior epigastric perforators, profunda artery perforator, lumbar artery perforator, bipedicled, and stacked) where a supervised trainee completed the microvascular anastomosis.

METHODS

 Retrospective chart review was performed on 413 flaps (190 patients) with microvascular anastomoses performed by postgraduate year (PGY)-4, PGY-5, PGY-6, PGY-7 (microsurgery fellow), or attending physician (AP). Comorbidities, intra-operative complications, revisions, operative time, ischemia time, return to operating room (OR), and flap losses were compared between training levels.

RESULTS

 Age and all comorbidities were equivalent between groups. Total operative time was highest for the AP group. Flap ischemia time, return to OR, and intraoperative complication were equivalent between groups. Percentage of flaps requiring at least one revision of the original anastomosis was significantly higher in PGY-4 and AP than in microsurgical fellows: PGY-4 (16%), PGY-5 (12%), PGY-6 (7%), PGY-7 (2.1%), and AP (16%), p = 0.041. Rates of flap loss were equivalent between groups, with overall flap loss between all groups 2/413 (<1%).

CONCLUSION

 With regard to flap loss and microsurgical vessel compromise, lower PGYs did not significantly worsen surgical outcomes for patients. AP had the longest total operative time, likely due to flap selection bias. PGY-4 and AP groups had higher rates of revision of original anastomosis compared with PGY-7, though ultimately these differences did not impact overall operative time, complication rate, or flap losses. Hands-on supervised microsurgical education appears to be both safe for patients, and also an effective way of building technical proficiency in plastic surgery residents.

Biosensors, Biomarkers and Biometrics: a Bootcamp Perspective

Introduction

Competitive physical performance is routinely monitored by wearable technology (biosensors), yet professional healthcare is not, despite high prevalence of trainee stress and burnout, notwithstanding the corresponding risk to patient safety. This study aimed to document the physiological stress response of UK Core Surgical Trainees (CSTs) during simulation training.

Methods

CSTs (n=20, 10 male) were fitted with Vital Scout Wellness Monitors (VivaLNK, Campbell, California, USA) for an intensive 3-day training bootcamp. In addition to physiological parameters, CST demographics, event diaries and Maslach Burnout Inventory scores were recorded prospectively during exposure to three scenarios: interactive lectures, clinical skills simulation and non-technical (communication) training.

Results

Baseline heart rate (BHR, 60 bpm (range 39–81 bpm)) and baseline respiratory rate (14/min (11–18/min)) varied considerably and did not correlate (rho 0.076, p=0.772). BHR was associated with weekly exercise performed (66 bpm (<1 hour) vs 43 bpm (>5 hour), rho −0.663, p=0.004). Trainee response (standardised median heart rate vs BHR) revealed heart rate was related proportionately to lectures (71 bpm, p<0.001), non-technical skills training (79 bpm, p<0.001) and clinical skills simulation (88 bpm, p<0.001). Respiratory rate responded similarly (p<0.001 in each case). Heart rate during clinical skills simulation was associated with emotional exhaustion (rho 0.493, p=0.044), but maximum heart rate was unrelated to CSTs’ perceived peak stressors.

Discussion

Stress response, as derived from positive sympathetic heart rate drive varied over two-fold, with a direct implication on oxygen uptake and energy expenditure, and highlighting the daily physical demands placed upon clinicians.

Operating Room Virtual Reality Immersion Improves Self-Efficacy Amongst Preclinical Physician Assistant Students

OBJECTIVE

To assess the impact on self-efficacy for preclinical physician assistant (PA) students through immersive virtual reality (VR) operating room simulation.

DESIGN

Randomized double-blinded controlled experiment measuring self-efficacy using Schwarzer and Jerusalem's general self-efficacy scale. An entirely novel operating room was created, casted, and filmed using VR software. Fifty-two preclinical PA students were randomly assigned to VR (n = 26) or traditional lecture (n = 26) and self-efficacy was measured in both conditions using a general self-efficacy scale given before and after the virtual experience. A mixed ANOVA, independent sample t tests, and paired samples t tests were performed.

SETTING

Shenandoah University Physician Assistant program, Winchester, Virginia.

RESULTS

Exposure to VR training after the traditional lecture improves self-efficacy amongst PA students (p < 0.05). Exposure to VR improved self-efficacy compared to traditional methods (p < 0.05). There was no difference in self-efficacy amongst PA students with the traditional model (p < 0.05).

CONCLUSIONS

The introduction of VR simulation improved preclinical PA student self-efficacy in the operating room setting.

Anxiety levels among health sciences students during their first visit to the dissection room

BACKGROUND

The teaching of human anatomy is often based on practices of cadaver dissection and prosected specimens. However, exposure to human cadavers might be stressful and anxiety-inducing for students. The aim of this study is to explore the degree of satisfaction and anxiety among first-year students in the Medicine, Occupational Therapy, Speech Therapy and Nursing programmes at the Universidad de Castilla-La Mancha (Spain) who are experiencing their first dissection/prosection practice to develop stress coping strategies.

METHODS

A total of 204 health sciences students participated in this study. The State-Trait Anxiety Inventory was used to evaluate anxiety.

RESULTS

'State Anxiety' (SA) decreased significantly throughout the course (p < 0.05), from 20.7 ± 19.29 to 13.7 ± 11.65 points. Statistical differences (p < 0.05) in SA were found between the different health sciences, and pre-practice SA was significantly different from post-practice SA. The students with the highest pre-practice SA levels were nursing students (31.8 ± 33.7 points), but medical students had the highest post-practice SA levels (18.4 ± 12.82 points).

CONCLUSIONS

Although students were satisfied with dissection practices (96.8% of them recommended that the practices be retained for future courses), the experience can provoke stressful responses that must be addressed using advanced preparation and coping mechanisms, especially among medical and nursing students.

Educators' behaviours during feedback in authentic clinical practice settings: an observational study and systematic analysis

BACKGROUND

Verbal feedback plays a critical role in health professions education but it is not clear which components of effective feedback have been successfully translated from the literature into supervisory practice in the workplace, and which have not. The purpose of this study was to observe and systematically analyse educators' behaviours during authentic feedback episodes in contemporary clinical practice.

METHODS

Educators and learners videoed themselves during formal feedback sessions in routine hospital training. Researchers compared educators' practice to a published set of 25 educator behaviours recommended for quality feedback. Individual educator behaviours were rated 0 = not seen, 1 = done somewhat, 2 = consistently done. To characterise individual educator's practice, their behaviour scores were summed. To describe how commonly each behaviour was observed across all the videos, mean scores were calculated.

RESULTS

Researchers analysed 36 videos involving 34 educators (26 medical, 4 nursing, 4 physiotherapy professionals) and 35 learners across different health professions, specialties, levels of experience and gender. There was considerable variation in both educators' feedback practices, indicated by total scores for individual educators ranging from 5.7 to 34.2 (maximum possible 48), and how frequently specific feedback behaviours were seen across all the videos, indicated by mean scores for each behaviour ranging from 0.1 to 1.75 (maximum possible 2). Educators commonly provided performance analysis, described how the task should be performed, and were respectful and supportive. However a number of recommended feedback behaviours were rarely seen, such as clarifying the session purpose and expectations, promoting learner involvement, creating an action plan or arranging a subsequent review.

CONCLUSIONS

These findings clarify contemporary feedback practice and inform the design of educational initiatives to help health professional educators and learners to better realise the potential of feedback.

Stress among medical students during clinical courses: a longitudinal study using contextual activity sampling system

OBJECTIVES

To investigate medical students' experiences of stress and other emotions related to their professional roles, as defined by the CanMEDS framework, by using the Contextual Activity Sampling System (CASS).

METHODS

Ninety-eight medical students agreed to participate of whom 74 completed this longitudinal cohort study. Data was collected between 6th and 8th term via CASS methodology: A questionnaire was e-mailed to the participants every 3rd week(21questionnaires/measurements) during clinical rotations and scientific project work term. Emotions were measured by a 7-point Likert scale (e.g., maximum stress = 7). Answers were registered through mobile technology. We used a linear mixed-model regression approach to study the association between stress over time in relation to socio-demographic and learning activities related to CanMEDS roles.

RESULTS

Participants completed 1390 questionnaires. Mean stress level over all time points was 3.6. Stress was reported as highest during the scientific project term. Learning activities related to 'Communicator,' 'Collaborator,' 'Scholar,' 'Manager' and 'Professional' were associated with increased stress, e.g. 'Scholar' increased stress with 0.5 points (t₍₁₃₃₉₎=3.91, p<0.001). A reduced level of stress was associated with 'Health Advocate' of 0.39 points (t₍₁₃₃₈₎=-2.15, p=0.03). No association between perceived stress and demographic factors, such as gender or age was found.

CONCLUSIONS

An association between different learning activities related to CanMEDS Roles and feelings of stress were noted. The CASS methodology was found to be useful when observing learning experiences and might support educational development by identifying course activities linked to stress.

Case Difficulty, Postgraduate Year, and Resident Surgeon Stress: Effects on Operative Times

OBJECTIVE

We aimed to evaluate resident operative times in relation to postgraduate year (PGY), case difficulty and resident stress while performing a single surgical procedure.

DESIGN

We prospectively examined operative times for 268 laparoscopic cholecystectomies, and analyzed relationships between PGY, case difficulty, and resident surgeon stress utilizing electrodermal activity. Each case operative times were divided into 3 separate time periods. Case Start and End times were recorded, as well as the time between the start of the operation and the time until the cystic structures were divided (Division). Case difficulty was determined by multiple trained observers with a high inter-rater concordance.

SETTING

University of Missouri, a tertiary academic medical institution.

PARTICIPANTS

All categorical general surgery residents at our institution.

RESULTS

For each operative time period examined during laparoscopic cholecystectomy, operative time increased, with each incremental increase in difficulty resulting in approximately 130% longer times. Minimal differences in operative times were seen between PGY levels, except during the easiest cases (Start-End times: 38.5 ± 10.4 minutes vs 34.2 ± 10.8 minutes vs 28.9 ± 10.9 minutes, p 0.002). Resident stress poorly correlated with operative times regardless of case difficulty (Pearson coefficient range 0.0-0.22).

CONCLUSIONS

Operative times are longer with increasing case difficulty. PGY level and resident surgeon stress appear to have minimal to no correlation with operative times, regardless of case difficulty.

Unpacking the Literature on Stress and Resiliency: A Narrative Review Focused on Learners in the Operating Room

PURPOSE

The operating room is a high pressure environment for surgical trainees as they attempt to reach a high level of performance in the midst of a multitude of stressors. The purpose of this work was to examine the relationships between stress, coping, and psychological resilience and their effects on performance and learning in surgical training.

METHODS

A narrative review was carried out of the existing literature on stress, coping, and resilience in surgeons and surgical trainees. Multiple fields of study were examined including medical education, surgery, surgical safety, anesthesia, workplace ergonomics, and psychology.

RESULTS

Sources of intraoperative stress include fatigue, disruptions, interpersonal conflicts, time pressure, a complex case or high risk patient, surgical errors, and surgeon temperament. These stressors can negatively impact the performance of surgeons and trainees and may inhibit learning. How a learner responds to stress in the operating room is highly variable and influenced by the context of the stress, the coping mechanisms available, and individual psychological resilience. Stress management techniques, such as mental rehearsal, are beneficial for reducing stress. Resilience is protective against stress and burnout, and resilience training is useful for reducing stress and improving mental health in physicians and medical students.

CONCLUSIONS

Surgical trainees experience significant stress in the operating room and their experience of stress is modulated by cognitive and behavioral factors. Further research is required on the development of effective interventions to help trainees manage intraoperative stress, with the potential to improve surgical performance, learning, and patient safety.

The impact of a competitive learning environment on hormonal and emotional stress responses and skill acquisition and expression in a medical student domain

The concept of competition has implications for educational contexts, as hormonal and emotional changes under competitive stress can modulate learning and memory processes. This study examined the impact of a competitive learning environment and associated hormonal and emotional responses on skill acquisition and expression in a medical domain. Using a cross-over design, sixteen male medical students participated in a competitive (in pairs facing each other) and non-competitive (alone) learning situation. In each treatment, an instructional video was followed by a timed straight-line suture evaluation with anxiety and competitiveness recorded. Salivary testosterone (T) and cortisol (C) were assessed at rest, before and after evaluation to quantify changes in T (ΔT) and C (ΔC). These procedures were followed by two sessions of self-directed training before retesting. Paired learning produced a larger positive ΔT (5.9-7.8% vs. 2.0-5.3%) and ΔC (7.6% vs. 3.3%), which was accompanied by more anxiety and elevated competitiveness (p < .01). Anxiety declined and suturing abilities improved over time (p < .001), irrespective of the learning approach, with resting C concentrations decreasing when learning alone (p < .05). Some ΔT and ΔC measures correlated (r = 0.40 to 0.65) with anxiety and competitive desire with paired learning only, whereas the ΔC was linked to suturing performance (r = -0.35) when learning alone. In summary, a tacit competition in a natural learning situation promoted more pronounced hormonal and emotional responses. However, skill acquisition and its expression improved to a similar extent in both situations of competitive and non-competitive assessment. Different adaptive pathways for skill expression and development emerged from this work.

A Vascular Anastomosis Simulation Can Provide a Safe and Effective Environment for Resident Skills Development

OBJECTIVE

Vascular anastomoses are complex surgical procedures, performed in time-sensitive circumstances, making intraoperative teaching more challenging. We sought to evaluate whether a vascular anastomosis simulation was effective in developing resident skills.

DESIGN, SETTING, PARTICIPANTS

General surgery residents participated in a vascular anastomosis simulation for 1 to 2hours during their transplant rotation. An attending transplant surgeon at the University of Colorado guided the resident through end-to-end and end-to-side anastomoses using bovine carotid artery (Artegraft). The residents completed a presimulation and postsimulation survey which quantitated their confidence. They also completed the MiSSES scale, which assessed the validity of the simulation.

RESULTS

Twenty residents participated in the simulation and completed the surveys. The residents reported increased understanding in how to set up an end-to-end anastomosis and an end-to-side anastomosis (p = 0.001 and p = 0.009, respectively). They reported increased ability to suture, forehand and backhand with a Castro-Viejo needle driver (both p < 0.001). The residents reported increased ability to manipulate the needle (p = 0.006), and increased ability to manipulate tissue without causing trauma (p = 0.021). They reported increased confidence in tying a surgical knot with 6-0 Prolene and in operating while wearing loupes (p = 0.002, and p < 0.001, respectively). Overall, the residents reported increased confidence when asked to perform part of a vascular anastomosis in the operating room (p < 0.001). Seventeen residents completed the MiSSES scale with median scores of "somewhat agree" to "strongly agree" on all domains of the scale.

CONCLUSIONS

The use of a simple, inexpensive vascular anastomosis simulation is an effective and safe environment to improve residents' surgical skills and the residents felt that the simulation was valid.

Medical Students' Use of Different Coping Strategies and Relationship With Academic Performance in Preclinical and Clinical Years

Phenomenon: Medical students' coping abilities are important for academic success and emotional health. The authors explored differences in students' use of active, problem-solving strategies and emotional, inwardly directed approaches; the change in coping strategies used during medical school; and coping strategy impact on performance.

APPROACH

One hundred eighty-three students completed the Ways of Coping Scale at matriculation and end of the 2nd and 3rd years. Frequency of each of 8 ways of coping, changes in coping strategy use over time, and relationship of coping method with preclinical and clinical scores were calculated.

FINDINGS

Students varied widely in use of coping mechanisms. Over time, students shifted to using emotional strategies more frequently while decreasing their use of active strategies. Coping strategies were unrelated to preclinical academic performance (R² = .09, adjusted R² = .04, ns) but were related to clinical performance (R² = .23, adjusted R² = .18, p < .0001), with active coping associated with higher performance and emotional methods associated with lower performance. Insights: Students decreased use of active coping strategies and increased use of emotional coping strategies over time, but emotional strategies were associated with poorer clinical academic performance. These shifts in coping methods may be detrimental to student performance and learning. Improving students' ability to cope should be an educational priority.