Bone and Joint Institute

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

Document Type


Publication Date



Journal of Surgical Education





First Page


Last Page


URL with Digital Object Identifier



© 2018 Association of Program Directors in Surgery 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.

Find in your library