Work

Assessing Cognitive Workload and Performance in the Operating Room: Challenges in Applying NASA ‐ TLX Among Experienced Surgeons

Year: 2026

Type: article

Abstract: BACKGROUND: Surgical performance and cognitive workload (CWL) are central determinants of operative outcomes. Most prior studies have relied on simulated environments, limiting their clinical relevance. This pilot study aimed to evaluate the feasibility of using the National Aeronautics and Space Administration Task Load Index (NASA-TLX) to measure task related CWL in operating theatres and investigate the relationship between CWL and technical performance using validated assessment tools. METHODS: A prospective, multicentre study was undertaken across seven Australian hospitals. Five expert surgeons performed 61 minimally invasive operations, including right hemicolectomies and secondary gastric bypasses. Surgeons self-reported CWL using NASA-TLX. Technical performance was independently evaluated using validated instruments: global operative assessment of laparoscopic skills (GOALS), global evaluative assessment of robotic skills (GEARS), bariatric objective structured assessment of technical skills (BOSATS) and a right hemicolectomy-specific scale. Scores were stratified into proficiency tiers and correlated with workload indices. RESULTS: Workload scores varied substantially within and across surgeons. Some demonstrated narrow workload distributions, while others exhibited broader ranges. Median baseline scores differed between individuals. Inter-assessor agreement was substantial (κ = 0.73, p < 0.001). Overall proficiency was high, although seven of 61 cases showed notable technical errors, with proficiency scores below eight out of 10. No strong correlation was identified between NASA-TLX scores and performance measures. CONCLUSION: This study demonstrated the feasibility of using NASA-TLX to assess overall CWL during live surgery and linking objective metrics to performance. Substantial inter-surgeon variability in workload and proficiency was observed. No significant association between CWL and performance was identified among expert surgeons in this study. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry (ANZCTR): 126200001943.

Source: ANZ Journal of Surgery

DOI: 10.1111/ans.70589