Investigators assessed surgeons’ performance under stress in the OR. The researchers found surgeons’ stress and workload negatively affected their non-technical skills, such as communication, situational awareness, and decision-making.1

“There’s been quite a lot of research into negative effects of stress on technical team performance,” says Nicholas E. Anton, MS, surgical skills coach and researcher at Indiana University School of Medicine. “With this study, we wanted to study the effects of stress on non-technical aspects of performance, which we know are important. Surgeons have to make sound clinical decisions and maintain awareness during procedures.”

There is a lack of understanding how stress affects surgeons’ work in communication, leadership, situational awareness, and effective decision-making. Researchers asked the primary surgeons to self-report their mental and physical demands and how stressful various situations were during procedures. Surgeons also reported whether they felt distracted and on the complexity of a case.

“Observers rated their decision-making. When we analyzed for a correlation between that observer-based rating and [physicians’ self-reported stress], we saw a negative correlation between situational awareness and perceived stress,” Anton explains. “When stress is high, decision-making is worse or situational awareness is worse.”

Anton and colleagues also observed connections between surgeons’ familiarity with their team and stress levels. “If the surgeon was more familiar with the team, the surgeon’s stress was lower. Less familiar meant higher stress,” Anton says. “This was from both observers and surgeons; non-technical skills were reported by observers, and stress and workload were reported by surgeons.”

A solution is for surgeons to learn skills that help them prevent stress from affecting their performance. “I’ve been working with surgical residents to learn several of these skills through a dedicated, mental skills curriculum,” Anton says. “We worked with two performance psychologists, and it was developed by a grant.”

Using cognitive visual modules and guided reflection, the curriculum teaches the following:

Develop action plans. One module helps residents develop goal-setting and action plans. “We also have them develop an ideal performance state where they reflect on a time when they felt they gave their best-ever surgical performance, and they identify their emotional state during that performance,” Anton says. “They can identify both positive emotions like confidence and calmness and also negative emotions like anxiety and tension.”

Manage energy effectively. “If one is too stressed, how do you reduce their stress for it to be in their ideal performance state?” Anton asks. “They can focus on step-wise actions to execute a task.”

Then, they reduce some of their stress — but not eliminate it entirely. “Some stress is really good for performance. It keeps us engaged, alert, and focused,” Anton explains. “We’re trying to help people identify what is their threshold for stress, which is different for each individual.”

Manage attention and focus. “We use mindfulness to identify when attention is off target and to be able to redirect focus back to the action plans,” Anton says.

Identify maladaptive thoughts. Participants are asked to identify any negative thoughts related to performance. “How we develop believable counters to those negative thoughts, essentially, is cognitive reframing,” Anton explains.

Use mental imagery. For surgeons, mental imagery is practicing surgical performance in the mind, in the absence of physical stimuli.

Refocus strategies. “We, essentially, develop contingency plans for if certain events happen that pull our focus,” Anton says. “What are the triggers for the loss of focus?” The goal for surgeons is to anticipate what they will encounter in the OR and use their skills to refocus. This starts with a centered breathing and conceptualizing their action plans for performance.

Develop performance routines. “There are logical points prior to and during procedures where there are natural breaks,” Anton says. “I want residents to consider what are ways they can lock into the case mentally.”

One component is pre-performance routines. “Maybe the night before a procedure, identify aspects of the case that the resident is likely to perform or potential difficulties they may encounter and rehearse what they would do in those situations,” Anton suggests. “Those are where mental imageries would apply, to think through how they would ideally perform the case." 


  1. Anton NE, Athanasiadis DI, Karipidis T, et al. Surgeon stress negatively affects their non-technical skills in the operating room. Am J Surg 2021; Jan 30;S0002-9610(21)00053-2. doi: 10.1016/j.amjsurg.2021.01.035. [Online ahead of print].