Authors: Mark R Wilson Jamie M Poolton Neha Malhotra Karen Ngo Elizabeth Bright Rich S W Masters
Publish Date: 2011/05/20
Volume: 35, Issue: 9, Pages: 1961-
Abstract
The purpose of the present study was to develop and validate a multidimensional surgeryspecific workload measure the SURGTLX and to determine its utility in providing diagnostic information about the impact of various sources of stress on the perceived demands of trained surgical operators As a wide range of stressors have been identified for surgeons in the operating room the current approach of considering stress as a unidimensional construct may not only limit the degree to which underlying mechanisms may be understood but also the degree to which training interventions may be successfully matched to particular sources of stressThe dimensions of the SURGTLX were based on two current multidimensional workload measures and developed via focus group discussion The six dimensions were defined as mental demands physical demands temporal demands task complexity situational stress and distractions Thirty novices were trained on the Fundamentals of Laparoscopic Surgery FLS peg transfer task and then completed the task under various conditions designed to manipulate the degree and source of stress experienced task novelty physical fatigue time pressure evaluation apprehension multitasking and distractionThe results were supportive of the discriminant sensitivity of the SURGTLX to different sources of stress The subfactors loaded on the relevant stressors as hypothesized although the evaluation pressure manipulation was not strong enough to cause a significant rise in situational stressThe present study provides support for the validity of the SURGTLX instrument and also highlights the importance of considering how different stressors may load surgeons Implications for categorizing the difficulty of certain procedures the implementation of new technology in the operating room man–machine interface issues and the targeting of stress training strategies to the sources of demand are discussed Modifications to the scale to enhance clinical utility are also suggestedThe surgical operating room is a multifaceted environment that exposes operating surgeons and their teams to considerable stressinducing conditions Challenges such as procedure complexity time pressure peer evaluation multitasking and distractions all have the potential to raise levels of intraoperative stress 1 2 Despite the multiple stressors that surgeons may face they are more likely to deny potential effects of stress on their performance than individuals in other challenging environments 3 Such an attitude has discouraged applied research in the field and limited organizational and educational change policies 4 As intraoperative stressors are seldom factored in as potential contributors to surgical outcome there are also significant negative implications for patient care and safetyStress is experienced when perceived resources are outweighed by demands 5 6 Given that multiple sources of stress have been identified one weakness of current research is that it adopts a unidimensional approach to measurement While validated instruments such as the State Trait Anxiety Inventory STAI 7 provide a measure of emotion anxiety other mechanisms may underpin the stressperformance relationship Indeed different stressors are likely to cause surgical performance to break down for different reasons Considering stress as a unidimensional construct not only limits the degree to which underlying mechanisms may be understood but also the degree to which a training intervention may be successfully matched to a particular source of stressFew studies in surgery have attempted to gain insight into the specific demands imposed on surgeons by typically experienced stressors In the fields of aviation and industrial ergonomics however the study of mental demand workload has been a major area of inquiry as researchers have sought to examine the potential causes of poor performance linked to increased workload 8 9 10 11 Workload is a multifaceted construct determined by the interaction of the task demands the circumstances under which the task is performed and the skills behaviors and perceptions of the individual 12 13 It is apparent from this definition that anxiety stress may be but one factor with an impact on the demands of the taskThe most widely used measure of workload in human factors research has been the NASATask Load Index NASATLX 14 is a multidimensional rating scale that has six bipolar dimensions mental demand MD physical demand PD temporal demand TD own performance P effort E and frustration F The dimensions therefore reflect taskrelated MD PD TD subjectrelated P and behaviorrelated F and E factors While multidimensional measures provide stronger diagnosticity ie the capability of an instrument to discriminate between different types of workload 9 13 a weakness is that they are generally created for a specific environment or task and therefore may not reflect different dimensions of workload in other environments 15
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