How Psychological State Affects the Operating Room (OR)

Many factors affect the operating room (OR) and surgery success, ranging from patient-related factors to resource-related factors to even clinician-related factors. Research has demonstrated that a patient’s psychological state can play a role; in addition, the psychological state of clinicians can also impact the OR. Developing techniques to accurately measure and study the psychological state of the surgical team in the OR is critical, along with techniques to address detrimental states.

Acute stress, the most common and detrimental psychological state observed in the OR, has been associated with negative patient outcome. Stress can impair cognitive functions and behaviors, leading to a self-centered and narrow focus which hampers information processing and the development of a common understanding among team members. Stress often causes individuals to concentrate solely on their own tasks, neglecting team unity and effectiveness and leading to suboptimal patient outcomes. In the operating room (OR), teamwork is crucial for ensuring patient safety. Teams that handle stressful situations well demonstrate a shared mental model and thus share a common understanding of the situation, its demands, and potential coping strategies. The quality of OR teamwork can be evaluated using the Observational Teamwork Assessment for Surgery (OTAS), which measures the physical, cognitive, and emotional aspects of stress through a six-item survey probing feelings of calmness, tension, upset, relaxation, contentment, and worry. [1]

Arora et al. describe another tool for measuring the stress component of psychological state in the OR for research – the Imperial Stress Assessment Tool (ISAT). The ISAT evaluates stress using both objective measures such as heart rate and cortisol levels, and subjective reports. Surgeons use a Polar S710i heart rate monitor for continuous tracking, and saliva samples for cortisol analysis are collected before and after each surgery. Finally, emotional, physical, and cognitive stress aspects are measured using the abbreviated version of the State Trait Anxiety Inventory (STAI) by Speilberger et al. Arora et al. have associated high stress profiles with personnel that demonstrate low expertise. Thus, stress from the demands of performing intricate procedures, learning to use new technologies, and the necessity to work quickly and efficiently are compounded by a lack of experience. Stress compromises technical abilities, alertness, memory, and other cognitive functions.

Unfortunately, research in this area is underwhelming despite its real-world impact in the field. Limitations within the literature include nonuniform stress measures – for example, heart rate (HR), skin conductance, eye blinks, and cortisol levels which have not been duplicated or the reliance on a single objective metric. Heart rate as the sole measure of stress in a study is unreliable since heart rate fluctuates under both physical exertion and mental stress. Another limitation is a failure to incorporate more subjective assessments alongside objective ones like heart rate. Subjective assessments matter since an individual’s psychological perception of stress is more directly linked to their behavioral response and their performance. [2]

Environmental triggers for stress are as important as the personal, relational, and educational triggers. Arabaci and Onler have noted that elevated noise levels in the operating room (OR) correspond with higher anxiety and workload scores among the staff. Research has consistently indicated that distractions from excessive noise can hinder the OR team’s focus, potentially undermining their execution of sterile practices, thus increasing the risk of surgical site infections. Noise during operations can interfere with the OR team’s cognitive functions and task performance. Noise compromises communication, posing a risk to patient safety while escalating stress among OR personnel. The sources of OR noise include alarms, medical apparatus, HVAC systems, acoustic properties of the OR surfaces, phones, music players, non-patient-centered conversations, and the flow of people in and out of the OR. The development of quieter surgical equipment, reducing commuter traffic within the OR, diminishing the likelihood of non-surgical communication and tools in the OR are steps towards mitigating noise pollution. [3]

Current research suggests that the psychological state of clinicians is important to performance in the OR, with real impacts on patient wellbeing. Further research should probe strategies to improve this state in both the short and long term.

References

1. Hull, Louise, et al. “Assessment of Stress and Teamwork in the Operating Room: An Exploratory Study.” The American Journal of Surgery, vol. 201, no. 1, Jan. 2011, pp. 24–30, https://doi.org/10.1016/j.amjsurg.2010.07.039.

2. Arora, Sonal, et al. “The Imperial Stress Assessment Tool (ISAT): A Feasible, Reliable and Valid Approach to Measuring Stress in the Operating Room.” World Journal of Surgery, vol. 34, no. 8, 15 Apr. 2010, pp. 1756–1763, https://doi.org/10.1007/s00268-010-0559-4. Accessed 2 Feb. 2022.

3. Arabacı, Ayşen, and Ebru Önler. “The Effect of Noise Levels in the Operating Room on the Stress Levels and Workload of the Operating Room Team.” Journal of PeriAnesthesia Nursing, Oct. 2020, https://doi.org/10.1016/j.jopan.2020.06.024.