Selecting experiences in the OR

The OR is a ‘…complex and highly charged workplace…” (Lyon and Brew, 2003, p.53) and is thus a challenging environment for learners to make sense of their experiences. Lyon and Brew investigated the OR as a learning environment from the perspective of medical students attached to surgical specialties. They claimed this as the first empirical study to examine how medical students learnt in the OR. They used a mixed methods approach. They twice

interviewed seven medical students as a group, observed in the OR on 12 occasions and undertook in-depth interviews with 15 medical students and ten surgeons. They also surveyed 197 out of 237 medical students.

Their data illustrated the many challenges faced by the students when they visited the OR for teaching. They grouped these challenges into three domains. The first related to the demands of the working environment, which was unpredictable and disorientating. The second related to managing the educational tasks, when they needed to form a clear idea of their objectives and relevance. The third related to how they managed their learning and the social interactions while working in the OR. The challenges posed to the medical students learning in the OR is summarised here.

‘Students who reported successful learning experiences from the operating theatre had a measure of social competence to negotiate an active role to play in the surgical team. They had learned to negotiate the social relations of work in the operating theatre to find

a legitimate role to play in order to participate in the community of practice constituted by the operating theatre and its personnel.’ (Lyon and Brew, 2003, p.58)

The students’ first challenge was to negotiate their way though the physical and mental aspects of a new and perhaps alien environment. They were newcomers to a different

community of practice and they were very much on the periphery (Lave and Wenger, 1991). The OR could be a frightening environment for the students. They were intruding into an area of medical practice where most of the staff already had defined roles. As the staff were all dressed similarly, in scrubs, it was sometimes difficult for the students to identify who was who. They encountered new protocols and local traditions. Until the students had successfully negotiated these challenges and hurdles they were unlikely to make good use of their

experiences. Put another way, until the basic aspects of Maslow’s (1943) hierarchy of needs were met, namely physiological and safety, the student was unlikely to learn effectively. Once they had come to terms with the environment, the students with clear learning objectives had more useful learning experiences than those who did not. One observation was that

students sometimes spent a long time waiting for things to happen in the OR. Some students viewed this as wasted time that could have been used more effectively for other parts of their course, particularly when it had direct relevance to their formal assessments. At the time of the study the students had not been given specific learning objectives related to the OR. Their perception of the importance of learning in the OR was related to their perception of the relevance of the experience. For example, some students planning to become general

practitioners could see the relevance as it would help them in the future when they explained surgical procedures to their patients. In addition it would help them in their initial

postgraduate hospital training. Stark (2003) also reported the variability in the views of medical students as to the value of teaching in the OR. Some felt OR teaching was pointless particularly if they could not see what was going on. On the other hand when they were

scrubbed up and could see the operation it had some value. This finding emphasised the importance of learners identifying experiences relevant to their needs (Kolb et al., 1971). Until they identified an experience as important they were unlikely to make use of it to drive learning.

The third domain in the Lyon and Brew study (2003) highlighted the challenges of learning in the OR related to how the student interacted with the surgeon. The students who got involved in patient care, for example scrubbing up, found the OR experiences valuable. One interesting aspect was how the impetus for interaction seemed to have to come from the students rather than from the surgeons: ‘You have to show interest to get them to teach – you have to be pro-

active.’ (Lyon and Brew, 2003, p.60) Not surprisingly there was variability in how confident students were to initiate teaching from the surgeons. The less confident students tended to rate their OR experiences as less valuable than the more confident. This contributed to how

valuable students found their OR experiences.

Lyon (2004) has built on this model of OR learning and suggested three ways of improving student learning. She labelled the three phases as trust, legitimacy and peripheral

participation. Her first suggestion was that students should have a proper induction and orientation to the OR. This would enable them to feel less an outsider and less likely to make mistakes. This should help with their confidence and enable them to actively engage.

Likewise the surgeons are then more likely to trust them and let them participate.

Secondly, she suggested that surgical units should have clear and coherent expectations of the medical students. The role and right of the student to be in the OR should be defined and agreed i.e. their legitimacy to be in the OR should be established. Her third suggestion relates to the negotiation of the learning opportunities available on an individual basis. The suitability of OR sessions for teaching is variable and depends on the types of the patients, their

operations, and number of trainees and students present. For example, on occasions the case may be so complex that the surgeon will not be able to pay attention to the student’s learning. She recommends that the learning opportunities should be negotiated at the start of the operating session. This approach is sensible and appears simple. However, the challenge is to transfer these ideas into action in the real world.

Part of negotiating learning opportunities requires the teacher and the learner to agree their educational objectives. A taxonomy of educational objectives was described by Bloom et al. (1956) and can be used to provide a structure. They constructed a classification separating educational objectives into the cognitive, affective and psychomotor domains (Bloom et al., 1956; Krathwohl et al., 1964). The cognitive domain contains those objectives concerned with remembering or reproducing something that has been learnt. It has six hierarchical levels: knowledge, comprehension, application, analysis, synthesis and evaluation. While an

objective such as ‘knowledge of facts’ can be defined at one level and may be an end point in its own right, at a higher level of complexity it becomes a tool or a means to a more complex objective. This concept of objectives crossing levels of complexity is equally applicable to the other domains of learning. Examples relevant to anaesthesia training for the various cognitive hierarchical levels are shown in Table 1.

Table 1 Examples of anaesthesia objectives within the cognitive hierarchical levels

Cognitive Domain Level

Anaesthesia related examples

Knowledge Learn a list of the causes of sudden hypotension during anaesthesia Comprehension Explain the meaning of hypotension during anaesthesia

Application Record the blood pressure and tell me when the patient is hypotensive

Analysis Classify the causes of hypotension during anaesthesia

Synthesis Summarises different treatments and matches them effectively for different types of hypotension occurring during anaesthesia Evaluation Explain the reliability of your measurements of blood pressure

Classifying the affective domain was more difficult, partly because there were few evaluation techniques in regular usage. It contains objectives related to feelings, attitudes and emotion and is separated into the five levels of receiving, responding, valuing, organisation and characterisation (Krathwohl et al., 1964). Examples relevant to anaesthesia training of the various affective hierarchical levels are shown in Table 2.

Table 2 Examples of anaesthesia objectives within the affective hierarchical levels

Affective Domain Level

Anaesthesia related examples

Receiving Agrees to listen to what the trainer has to say about pain related to anaesthesia

Responding Discusses the affect of pain on the patients

Valuing Sympathetically attends to the pain requirement of the patients Organisation Discusses the benefits of protocols for pain therapy

Characterisation The trainee’s approach to intensive care reflects the importance placed on a logical and humanitarian approach to management of pain

Bloom et al. (1956) did not consider it appropriate to set hierarchical levels for the

psychomotor domain since very little was written about psychomotor objectives within the education literature at that time. However, since the psychomotor domain contains objectives related to performing practical skills, which are fundamental to all medical practitioners, this domain is also relevant. Simpson (1972) proposed a taxonomy of four levels namely

perception or awareness, simple motor skills, complex motor skills and the ability to

communicate. An alternative approach to viewing the psychomotor skills, particularly related to their assessment, was proposed by Miller (1990, p.s63) when he described a four stage pyramidal model: knows about, knows how, shows how and does. This is covered in more detail in section 2.6.2.

The importance of medical students having learning objectives for their OR attachment, as highlighted by Lyon (2004), has been explored by Fernando et al. (2007). They surveyed the

views of 46 final year medical students and 42 surgeons using a short questionnaire and identified five skills and competences that were deemed essential by most of the students and surgeons. These included: appreciation of standard OR etiquette and protocols; being able to adhere to sterile procedures; being aware of risks to self and staff; being aware of risks to patients; and appreciating the need for careful peri-operative monitoring. These findings were mainly about preparing students to participate in a new environment and community of practice. They confirm the suggestions made by Lyon (2004) that students need an orientation and specific learning objectives to be able to make the most of their OR experiences.

Fernando and colleagues have gone on to develop a DVD and learning guide (summer 2007) to act as their induction package.

The importance of defining learning outcomes and identifying learning experiences was also reported by Cox and Swanson (2002) when they were exploring teaching excellence in surgeons. The surgeons, who were rated as excellent teachers in the OR, had two

discriminating behaviours. The first was that they demonstrated sensitivity to the trainee’s learning needs. The second was that they provided direct feedback to their learners. This section has considered some of the challenges associated with learning within the complex world of the OR. The general principles to guide good learning are the same as elsewhere. These include having clear learning objectives and exposing the learner to appropriate experiences. The challenge relates to introducing the learner into a new

community so that they can participate and learn effectively. Only then can they make good use of the multiplicity of experiences available in the real world that is the OR.