Defence of Thesis 01 October 2026: Maria Suong Tjønnås – Faculty of Medicine and Health Sciences

PhD candidate Maria Suong Tjønnås at the Department of Neuromedicine and Movement Science, will hold a trial lecture and defend her doctoral thesis for the degree of Philosophiae Doctor (PhD). The degree is administered by the Faculty of Medicine and Health Sciences at the Norwegian University of Science and Technology (NTNU). Thesis title “Stress responses and experiences of surgical trainees during simulation-based training of laparoscopic surgical skills - Observation, exploration, and literature review” Trial lecture Assigned topic: “Stress in real life surgical settings - effects on surgical performance and patient-related outcomes” Assessment committee The Faculty of Medicine and Health Sciences has appointed the following members to the assessment committee for the evaluation of the thesis: First opponent: Associate Professor Flemming Bjerrum, University of Copenhagen Second opponent: Professor Hein Daanen, University of Amsterdam Chair of the committee: Assistant Professor Berit Brurok, NTNU The committee has concluded that the thesis is worthy of public defence for the PhD degree. Supervisors Main supervisor: Associate Professor Anita Das , Department of Neuromedicine and Movement Science, NTNU Co-supervisors: Senior Researcher Solveig Osborg Ose, Senior Researcher Mariann Sandsund and Senior Researcher Cecilie Våpenstad Time and venue The PhD trial lecture and defence of the thesis are both open to the public: Trial lecture: 01 October 2026 at 10:15 – Auditorium ØHA11, Øya Helsehus Thesis defence: 01 October 2026 at 12:15 – Auditorium ØHA11, Øya Helsehus Assistant Professor Berit Brurok will chair the trial lecture and public defence. Summary In this PhD project, the research aimed to advance understanding of both the physiological and subjective stress responses of surgical trainees, as well as their stress‑related experiences, during simulation‑based laparoscopic training conducted as part of mandatory educational courses. The work focused on identifying the specific tasks and procedures that elicit stress responses, as well as describing the various forms of stress experienced within surgical training environments. A central component of this research involved training surgical skills using a range of laparoscopic simulators across various simulation environments. The findings represented an initial step toward integrating knowledge of stress responses into simulation‑based surgical training, thereby strengthening skill development, and supporting trainee performance. Stress can significantly affect performance, acting as both a motivator and a detriment, and in surgical settings it can pose risks to patient safety. Surgical training focuses on developing technical skills, yet there is limited data on the stress response levels experienced by trainees. Stress responses, defined as physical and psychological reactions to demands that exceed coping capacity, affect performance and skill acquisition. While moderate stress levels can enhance task performance, excessive stress levels can impair technical skills. Laparoscopic skills training is particularly demanding and often triggers high stress response levels, especially in inexperienced trainees. Simulation-based training courses offer surgical trainees essential skills training by allowing repeated practice of laparoscopic techniques and procedures in an environment free from any risk to patients’ health. The main goal of these simulation-based training courses is to help trainees develop a higher level of proficiency in technical skills. Such training also provides a unique platform to investigate stress responses and experiences, and how these may influence on trainees’ training process and their performance outcomes. However, so far there has been limited data on stress responses and stress experiences from these environments. This PhD work combined observational studies of physiological and perceived stress with a systematic review on stress in surgical educational environments. Four studies were conducted and published. Study 1, a systematic review of the literature on stress in surgical education, found that heart rate and heart rate variability were the most used physiological stress response measures, while the State‑Trait Anxiety Inventory was the preferred psychological scale. Mental training interventions most consistently reduced stress. Stress influenced surgical ii performance in both positive and negative ways, with no clear overall pattern but clear implications for trainee performance and development. The findings showed that stress responses did influence surgical training and could affect both technical and non‑technical performance. Study 2, a qualitative study exploring stress experiences during basic laparoscopic skills training, found that trainees experienced a wide range of stressors. Three overarching themes emerged: simulation task requirements, levels of psychomotor skill, and internal pressures. Some stressors were inherent to the simulation tasks, while others reflected psychological pressures unrelated to the simulator itself. Self-imposed pressure strongly influenced performance, suggesting that moderate levels of perceived stress may enhance simulator performance. Study 3, a quantitative investigation of physiological, endocrine, and self-reported stress responses during basic laparoscopic skills training, showed that all three simulators elicited significantly higher physiological and subjective stress responses compared with resting conditions. Cortisol levels were significantly elevated during box‑trainer tasks, and moderate correlations indicated that more experienced trainees showed higher physiological stress but reported lower perceived stress. Study 4, an observational study comparing stress responses during advanced laparoscopic procedural training on box-trainers and live animal models, found no physiological stress response differences between the two simulation training environments. However, trainees reported higher perceived stress during operating room training, influenced by factor such as realism, perceived risk, and interpersonal dynamics. Trainees viewed this stress as beneficial for maintaining focus and performing advanced procedures. This thesis provided insights into physiological and subjective stress responses and explored trainees’ stress experiences during simulation‑based training in both basic laparoscopic skills and advanced procedures. It also offered a review of the literature on stress in surgical educational environments. Together, the studies highlighted the value of simulation‑based training, particularly for advanced laparoscopic procedures performed in realistic environments, and showed how understanding stress responses could support both trainee performance and instructor guidance. Recommendations for future research should examine how training environments can be calibrated so that stress levels align with trainees’ experience and learning goals. Low‑stress settings facilitate early skill acquisition, whereas high‑stress simulations support complex task performance and contextual learning. Measuring stress responses enables targeted feedback and task adjustments that help maintain facilitative stress levels, while structured reflection and iii instructor support further strengthen trainees’ stress‑management awareness and coping strategies. As an initial step toward understanding the role of stress responses in surgical training, the present findings underscore the need to further research factors that influence performance and learning outcomes.

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