Teaching and Learning in Medicine
An International Journal
ISSN: 1040-1334 (Print) 1532-8015 (Online) Journal homepage: www.tandfonline.com/journals/htlm20
How Do Early Emotional Experiences in the
Operating Theatre Influence Medical Student
Learning in This Environment?
David J. Bowrey & Jane M. Kidd
To cite this article: David J. Bowrey & Jane M. Kidd (2014) How Do Early Emotional Experiences
in the Operating Theatre Influence Medical Student Learning in This Environment?, Teaching
and Learning in Medicine, 26:2, 113-120, DOI: 10.1080/10401334.2014.883986
To link to this article: https://doi.org/10.1080/10401334.2014.883986
Published online: 04 Apr 2014.
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Teaching and Learning in Medicine, 26(2), 113–120
C 2014, Taylor & Francis Group, LLC
Copyright ISSN: 1040-1334 print / 1532-8015 online
DOI: 10.1080/10401334.2014.883986
APPLIED RESEARCH
How Do Early Emotional Experiences in the Operating
Theatre Influence Medical Student Learning
in This Environment?
David J. Bowrey
Department of Surgery, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
Jane M. Kidd
Educational Development & Research, Warwick Medical School, Coventry, United Kingdom
Background: The emotions experienced by medical students on
first exposure to the operating theatre are unknown. It is also unclear what influence these emotions have on the learning process.
Purposes: To understand the emotions experienced by students
when in the operating theatre for the first time and the impact of
these emotions on learning. Methods: Nine 3rd-year medical students participated in semistructured interviews to explore these
themes. A qualitative approach was used; interviews were transcribed and coded thematically. Results: All participants reported
initial negative emotions (apprehension, anxiety, fear, shame, overwhelmed), with excitement being reported by 3. Six participants
considered that their anxiety was so overwhelming that it was
detrimental to their learning. Participants described a period of
familiarization to the environment, after which learning was facilitated. Early learning experiences centered around adjustment to
the physical environment of the operating theatre. Factors driving initial negative feelings were loss of familiarity, organizational
issues, concerns about violating protocol, and a fear of syncope.
Participants considered that it took a median of 1 week (range =
1 day–3 weeks) or 5 visits to the operating theatre (range = 1–10)
before feeling comfortable in the new setting. Emotions experienced
on subsequent visits to the operating theatre were predominantly
positive (enjoyment, happiness, confident, involved, pride). Two
participants reported negative feelings related to social exclusion.
Being included in the team was a powerful determinant of enjoyment. Conclusions: These findings indicate that for learning in the
operating theatre to be effective, addressing the negative emotions
of the students might be beneficial. This could be achieved by a formal orientation program for both learners and tutors in advance of
attendance in the operating theatre. For learning to be optimized,
Both authors contributed to the conception and design of the study.
David J. Bowrey conducted and transcribed the interviews, performed
the data analysis and interpretation, and drafted the article. Jane M.
Kidd contributed to the analysis and interpretation of data and to critical
revision of the article. Both authors approved the final manuscript for
publication.
Correspondence may be sent to David J. Bowrey, Department
of Surgery, Level 6 Balmoral Building, Leicester Royal Infirmary,
LE15WW, United Kingdom. E-mail: djb57@le.ac.uk
students must feel a sense of inclusion in the theatre community of
practice.
Keywords:
medical students, operating room, emotions, learning
INTRODUCTION
Emotions have been shown in a number of nonmedical disciplines to have a profound influence on the learning process.1–3 A
small number of studies have examined the emotional response
to clinical situations in medical students (Table 1).4–13 These include real and simulated scenarios, including cardiac arrest,10,11
prescribing errors,8 first patient encounters,6 the dying patient,7
and cadaveric dissection.5,9 No prior study has assessed the
emotional response to the operating theatre, and in particular
the effect of these emotions on the learning process in medical
students.
In addition to examining the emotional response to clinical
situations, three of the aforementioned studies assessed how
emotions affected the learning process.8–10 One study noted that
emotions impaired learning,9 whereas two suggested that they
may enhance learning.8,10
The aim of the current study was to gain a greater understanding of the emotions experienced when students were placed in
the operating theatre environment for the first time during medical school and to assess how this impacted on their learning
processes. The most immediate utility of this information was
to inform recommendations about medical student learning in
the operating theatre.
METHODOLOGY
Participants
Eighty-three 3rd- or 4th-year students were sent a written
and e-mail invitation to participate while undertaking a clinical
113
114
D. J. BOWREY AND J. M. KIDD
TABLE 1
Summary of literature relating to first time emotional experiences in medical students
Emotions Experienced
No. of
Students
Setting
Method
Kasman et al. (2003)4
10a
Medical wards
I, D
Houwink et al. (2004).5
99
Q
Pitkala and Mantyranta
(2004)6
22
Cadaveric
dissection
Clinical
encounters
D
Joy, happiness,
sympathy
Rhodes-Kropf et al.
(2005)7
Fischer et al. (2006)8
32
Patient death
I, Q
Caring, valued, satisfied
30
Drug errors (S)
I
Arraez-Aybar et al.
(2008)9
425
Cadaveric
dissection
Q
DeMaria et al. (2010)10
Hunziker et al. (2011)11
25
120
Cardiac arrest (S)
Cardiac arrest (S)
RCT
Q
Lindstrom et al. (2011)12
75
D
Nordstrom et al.
(2011)13
10
“Shame”
experience
Death
notification (S)
Author
I
Positive
Gratitude, happiness,
compassion,
pride, relief
Negative
Anxiety, guilt, sadness, anger,
disgust, shame
Anxiety, disgust, guilt, sadness
Curiosity, interest,
calmness, pleasure,
satisfaction, happiness
Interest, pride, joy,
pleasure, relief
Excitement, relief,
at ease, focused
Anxiety, tension, insecurity, guilt,
confusion, uncomfortable,
helplessness, embarrassment,
inferiority
Sadness, shocking
Scared, guilty, embarrassed, fear,
anger, shame
Uncertainty, revulsion, anxiety,
worry, distaste, fear, loathing,
upset, horror
Anxiety
Irritation, disappointment, guilt,
shame, anxiety, desperation
Shame
Tension, anticipation, difficult,
nervous, insecure, unpleasant,
worried, upset, shocked,
stressed, inadequate, unfamiliar
Note. D = self-completed diary; I = interviews; Q = questionnaire; S = simulation.
a
Included faculty and residents.
attachment in Perioperative Care. This 7-week attachment
comprised the disciplines of Gastrointestinal and Vascular
surgery, and Anesthesiology, analogous to the 3rd-year Surgical
clerkship in North American medical schools. The study was
setup with the intention of recruiting up to 10 participants, split
over two clinical attachments during the period April to June
2012. This number was selected in part on pragmatic grounds,
for what could be achieved within the time constraints of the
study and in part on cost grounds, as the study was unfunded.
Students were sampled on pragmatic grounds, in that once the
first five from each attachment had volunteered to participate,
no further recruitment was undertaken.
Ethical Considerations
Ethical approval for the project was sought and granted by the
University of Warwick Biomedical Research Ethics Committee
approval (Reference 170-01-2012), each participant providing
written informed consent. The consent of the Director of Medical Education, University of Leicester was granted to recruit
students from that site. The rationale for University of Warwick
acting as sponsor for the study was because the work formed
the basis of an educational high degree at that institution.
Interview Setup
Table 2 indicates the interview schedule. Interviews were
conducted in two rounds in a private university seminar room
on the hospital campus. Each was scheduled for 30 minutes,
including time to gain consent from the participant and setup
the recording equipment. Interviews were audio-recorded and
subsequently transcribed verbatim.
Interview Analysis and Rationale for Use
of This Methodology
As there have been no previous studies assessing emotional experiences in the operating theatre, it was considered
most appropriate to use a qualitative approach.14 Further,
the majority of the published articles exploring emotional
responses to clinical encounters have employed qualitative
MEDICAL STUDENT EMOTIONS IN THE OPERATING THEATRE
115
TABLE 2
Semistructured interview schedule
Opening line: “I would like to explore the emotions that you experienced when in the operating theatre”
❖ Can you tell me what experience of the operating theatre you have had so far?
◦ Could you tell me more about that?
❖ Can you think back to the moment when you went to the operating theatre for the first time?
◦ How did you feel?
◦ What were your thoughts?
◦ Do you know why you felt this way?
◦ Did you feel prepared for the experience? Could you tell me more about that?
◦ How do you think your emotions affected your learning experience either positively or negatively?
❖ Can you now reflect on the last occasion you were in the operating theatre?
◦ How did you feel?
◦ What were your thoughts?
◦ Did your feelings differ from the first time that you were in theatre? Could you tell me more about that?
◦ Do you know why you felt this way?
◦ How do you think your emotions affected your learning experience either positively or negatively?
❖ Has your theatre experience made you more or less likely to consider a career in surgery?
❖ Is there anything else you would like to tell me?
Prompts to encourage interview to flow
❖ Could you reflect on your time in the operating theatre?
◦ What was the last operation that you saw? Could you tell me more about that?
◦ How many operations have you seen in this block? Ever?
❖ Did you get involved with any of the operations?
In what way? Did you get scrubbed up?
Have you had the opportunity to suture? How did that make you feel?
❖ Overall, did you enjoy your time in the operating theatre?
◦ Would you recommend the theatre where you were to your friends? Would you like to go back there?
Additional questions employed in the second round of interviews
❖ Were you involved in operations on patients who you had consulted with or spoken to beforehand?
◦ Were your feelings or emotions any different when in theatre with those patients compared to other patients whom you had
not seen beforehand?
❖ Is there any learning in the operating theatre that cannot be attained from learning in other environments?
◦ Do you consider it should be a requirement for students to attend the operating theatre?
methodology with thematic analysis. Semistructured interviews
were selected as the data collection method because reported
studies on similar subject matter generally employed one to
one interviews or analysis of self-completed reflective diaries.
It was considered that in disclosing emotions and potentially
sensitive information, a greater level of frankness and openness
would be obtained using one-to-one interviews. The interview
transcripts were typed, analyzed line by line, hand-coded by the
principal researcher (DJB), and had subthemes extracted. This
work formed part of a higher degree in medical education for
the principal researcher whose background was in Surgery, with
subspecialty interest in medical education. The coresearcher
(JK), as the thesis supervisor reviewed and verified the interview
transcripts. The coresearcher is director of Medical Education
Development and Research at Warwick Medical School and
has a background in clinical psychology.
Four interviews were conducted in April 2012 and five in June
2012. After the first round of interviews, no formal analysis was
conducted of the first interview sample, although the interviews
were played back in order to identify any obvious themes that
could be developed in the second round of interviews. Two
themes were identified for further exploration. These were the
“hidden curriculum” and whether familiarity with the patient
affected the emotional experience in the operating theatre.
Reflexivity. There are a number of potential sources of bias
to the current study, but attempts were made to minimize or
acknowledge the influence that these may have had. It is difficult
to extrapolate how representative the sample was of the entire
year cohort. The demographics of the participants were broadly
in keeping with their year cohort, the only difference being
an underrepresentation of undergraduate versus graduate entry
students. Whether this made a difference is unclear, although the
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D. J. BOWREY AND J. M. KIDD
findings have a number of similar themes to North American
studies, where all medical students are graduate entry. It should
also be borne in mind that the central tenet of qualitative research
is that the generalizability of the findings is less pertinent than
an appreciation that the findings are context related.
Attempts were made to minimize potential bias from the personal involvement of the principal researcher (DJB), who was
at the time the Clerkship Director for Perioperative Care. It appeared to the principal researcher that the participants gave full
and frank disclosure of their sentiments, thoughts, and feelings
about theatre teaching as can be evidenced by extracts of the
interviews included subsequently, although it is possible that
different responses would have been obtained if the interviews
had been conducted by an independent researcher. Other safeguards put in place were that none of the participants were
assigned to the researcher as supervisor during the course of the
block. These students were specifically excluded from participation. Finally, interviews were conducted on the final afternoon
of the block by which time the students had completed their
assessments to minimize any unintentional influence this might
have on student perceptions.
The study may also have been enhanced by coding the interviews in a sequential fashion, before conducting the subsequent
interview. Although the interviews were reviewed after the first
four had been undertaken, this was an audio playback without
transcription. The questions were modified as discussed in the
Methodology section, but wholesale changes were not made
to the conduct of the interviews between the first and second
iterations.
It was clear after replaying the recordings for transcription
that several of the participants struggled with the use of the term
“emotions,” and the researcher sensed this at the time of the
interviews. If further interviews were to be conducted, the term
“feelings” would be used as an alternative. It was the male participants who struggled more than their female counterparts. It is
possible that changing the terminology might have encouraged
a greater degree of openness than was achieved.
aspirations of the nine participants were anesthesiology (one),
emergency medicine (one), family practice (four), obstetrics and
gynecology (one), ophthalmology (one), and orthopedic surgery
(one). These are broadly representative of the year cohort, with
in excess of 50% of graduates entering family practice and
between 5% and 10% entering a surgical specialty.
RESULTS
Nine of the invited 83 students volunteered to be interviewed.
Other than a verbal and an e-mail invitation to participate, no
additional advertisement was employed. Four participants were
female and five male; seven were graduate entry students, one of
whom was taking the 5-year course, and two were undergraduate
entry students. Five participants were White British, two were
Asian British, one was Asian non-British, and one was Black
British. Compared to the demographics of the entire year cohort,
the study sample was broadly representative of the sex and
ethnic distribution of the year cohort, but it included a higher
proportion of graduate entry students. Six of the participants
undertook their block at one of the two teaching hospitals (four
at one hospital, two at the other), whereas three participants were
based, one in each of three district general hospitals. The career
2. Excitement at a new learning encounter (three participants):
Previous Operating Theatre Exposure
Four of the participants had never been into a hospital operating theatre previously, two had spent a day in theatre as part of
high school work experience, one had been involved in the placement of radiotherapy implants under general anesthesia while
working as a radiotherapist, one had visited an operating theatre
on several occasions to observe orthopedic surgery while working as a physiotherapist, and one had observed cardiothoracic
surgery for a week while working as an exercise physiologist.
The five participants with previous experience had little recollection of the events. This was attributed to the fact that they
were purely observers and that there were no expectations of
them. The only participant who could recall specific memories
related to work observation at a veterinary surgery clinic. This
had left a negative impression and a fear of syncope:
. . . it was mainly because I knew I, um, I was, there was a high
chance I would going to pass out because I’d been in work experience
in a veterinary clinic . . . uh, I think when I was about 16 and every
time I went into the theatres there, I would faint and it would be
really embarrassing . . . and so I was just . . . ok I wasn’t terrified . . ..
Initial Emotions
The initial emotions reported by participants were as follows:
1. Fear and apprehension related to the unknown environment
and a fear of violating operating theatre protocol (seven participants):
. . . it was a mix of apprehension because obviously I’d not
been in before really, I didn’t know where to go . . . um, I didn’t
know who to introduce myself to. . . . (Interview 2)
Excitement was because obviously it was something . . . new.
. . . (Interview 2)
3. Shame at being unable to answer theoretical questions and
because of admonishment over incorrect dress code (two
participants):
. . . I’d left me earrings in and a theatre nurse came out and
shouted at me . . . but for the first time, I didn’t know what to do
with myself, really. I just stood in the corner. (Interview 9)
Several participants had anticipated that they might feel “disgusted” but commented that this sensation was noticeably lacking “a feeling of a bit shock, but I wasn’t feel disgusted at all,
not at all” (Interview 1).
MEDICAL STUDENT EMOTIONS IN THE OPERATING THEATRE
Influence of Emotions on Learning on Initial Visit
to Operating Theatre
Six of the participants considered that their emotions had a
negative influence on their learning the first time they were in the
operating theatre, whereas three considered that their emotions
were a positive influence. There was no obvious clustering of
emotions among the two groups of participants (negative vs.
positive impact of emotions on learning). Indeed, two of the
three participants who considered that their emotions had a
positive influence on initial learning reported anxiety.
Five participants described a period of familiarization once
initially immersed in the new setting. A common response was to
“withdraw” from the situation by standing in a peripheral location within the operating theatre, minimizing contact with other
individuals. This response was noted even in the participants
who considered that their emotions were a positive influence on
their learning:
. . . so I would say, once I’d been there awhile and I’d calmed
down . . . but certainly at first, I’d say the first half an hour or so . . .
uh, I didn’t really take much in of anything. (Interview 2)
Familiarization Process
Although the interviews specifically compared emotional reactions to the operating theatre between the first and last visits to
the operating theatre, 6 weeks apart, most participants reported
a period of familiarization, after which they felt comfortable in
the theatre. The reported length of this familiarization time for
the six participants who commented on this varied from 1 day
to 3 weeks (one to 10 visits):
. . . probably halfway through the second week, we started to feel
more comfortable, and then I’d say by into the third week . . . um . . .
we knew um . . . how it all worked and how the system worked and
where to go um . . . to get the information even if we couldn’t talk to
the surgeon directly and that was, that was when I really started to
get most out of it. (Interview 2)
Social Inclusion
As well as familiarization with the physical workspace of the
operating theatre, participants reported the benefits of feeling
socially included within the operating theatre team. This was a
powerful determinant of perceived enjoyment:
I think what made me feel comfortable was the surgeon we had
was very welcoming and friendly and . . . made sure we were made
to feel part of the team, so I think within a week, I felt quite confident
in there . . . because he was involving us in whatever. . . . So then the
rest of the team kind of involved us as well, so he took the lead in
doing that . . . which really was good . . . so within a week or so I’d
say. (Interview 9)
Emotions Experienced on Final Visit
to the Operating Theatre
The emotions experienced by participants on their most recent visit to the operating theatre, 6 weeks after the initial visit
comprised the following:
117
1. Enjoyment (four participants) at new learning events. Three
participants commented that enjoyment related to social inclusion within the team. All but one participant reported
greater enjoyment on subsequent visits to the operating theatre compared to the initial experience:
I felt at home completely. I really enjoyed it. It was a fantastic
experience. (Interview 8)
2. Pride at the perception that the participants were contributing in a positive manner to beneficial patient outcome (two
participants), notably when assisting:
I felt like a hero, even though it was just closing a little bit of
skin but it meant that, that I was even more involved in the care
of the patient because I had a specific reason to go and see them
on the ward again. (Interview 8)
3. Two participants reported negative feelings around subsequent visits to the operating theatre. One participant reported
feelings of hurt at not being able to scrub up when he had
been able to on most other occasions. Another participant reported feelings of boredom and isolation at being effectively
ignored by the theatre team:
There was two registrar with the consultant so I don’t get to
scrub up . . . and, I feel a bit upset, because what I think is that
. . . if a student don’t get to scrub up . . . by watching from far,
I can’t watch anything, I can’t really see, I can’t appreciate it.
(Interview 1)
Emotional Connection With Patient
Two participants during the first round of interviews mentioned that they considered they had learned more when surgery
was undertaken on a patient that they had interviewed and consulted with preoperatively. To this end, the theme was explored
further in the second round of interviews (see Methods section
and interview schedule):
One of the most memorable patients to myself is a gentleman
that I’d seen in an outpatients clinic. He was then admitted, so we’d
gone to see him on the wards, I’d come and seen him before, um,
before he was anesthetized and then was with him throughout the
procedure, and then we saw him on the wards, um, a day or so later,
so actually there getting the full patient journey. (Interview 3)
This emotional connection with the patient extended to meeting
before surgery on the admission ward on the morning of surgery:
I would spend time with the patients beforehand, so before they
were anesthetized . . . um, and it’s actually talking to the patients
about their experience that a lot of them are scared . . . um . . . and
just by being there, it made me realize how much of a difference you
can actually make to the patients, holding their hand while they’re
having an epidural, things like that make a big difference to the
patient. (Interview 3)
DISCUSSION
The current study identified a combination of negative (apprehension, anxiety) and positive (excitement) emotions when
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D. J. BOWREY AND J. M. KIDD
medical students were initially in the operating theatre, with negative emotions predominating. There are some important similarities and differences in these findings compared to published
reports (Table 1). When asked to recall a clinical encounter that
had stimulated an emotional response, Kasman et al.4 identified
that anxiety was the second most frequently recorded emotion
(after happiness) among 10 medical students and faculty in Internal Medicine and Pediatrics.
Pitkala and Mantyranta6 thematically analyzed the reflective
diaries of 22 third-year medical student after clinical encounters.
The authors found that first patient encounters provided strong
emotional experiences for the students. The principal themes
that emerged in that publication related to strong negative feelings about confidence in one’s own knowledge and skills, patient
interaction, and the role as a “student physician.” Two further
subthemes identified by the authors related to “uncomfortable
feelings related to (patient) corporeality” and “shame related to
(patient) intimacy.” The current study found no evidence of these
negative emotions and the drivers for those emotions. There are
a range of potential reasons for this difference, not least that in
that study, the focus of the encounters was patient consultation,
and in the current study, patients were invariably under general
anesthesia. In the current study, it was more fears about inadequacy of knowledge and skills in the face of faculty rather than
patients that were evident. None of the participants in the current study mentioned uncomfortable feelings relating to patient
intimacy.
The current study identified that teaching involving humiliation or shame was experienced by two participants. For one,
the trigger was being admonished over theatre apparel by nursing staff, and for the other, being unable to answer questions
while in the theatre suite. In the current study, the experiences
of being in the operating theatre for the first time are reminiscent of the shame-inducing clinical encounters described by
Lindstrom et al.12 The authors found that such encounters were
characterized by circumstances often during the early portion of
clinical attachments, where the students perceived that they had
an inadequate knowledge base, where the encounter included
a number of onlookers, and where there was a perceived difference in seniority. Lempp and Seale15 noted that 19 of 36
medical students interviewed recalled teaching episodes that involved humiliation. The perpetrators were usually male senior
medical staff, but instances involving nursing and midwifery
staff treating students disrespectfully were also recorded.
Influence of Emotions on Learning
In the current study, six of nine participants considered that
their learning was impaired because of their levels of anxiety.
Three studies reported in the medical literature have identified
that emotions influence learning, one identifying anxiety to have
a negative influence9 and two identifying anxiety as a positive
influence.8,10 Arraez-Aybar et al.9 noted that 20% of students
reported an impairment in learning because of strong emotional reactions when initially exposed to cadaveric dissection.
Fischer et al.8 reported that medical students and Internal
Medicine trainees reflecting on either an actual or a simulated
severe prescribing error concluded that the negative emotions
associated with the event served as a powerful learning aid.
Finally, DeMaria et al.10 observed improved cardiopulmonary
resuscitation skills for students undergoing simulated cardiac arrest with emotional stressors compared to without. These effects
proved durable in nature. The authors concluded that “there is
probably a range of stress that is optimal for learning, and a range
that induces so much anxiety that it compromises an educational
experience” (p. 1012). The familiarization process observed in
the current study is akin to this.
Teamwork and Social Inclusion
The current study identified that teamwork and feeling included in the operating theatre team were powerful determinants of medical student enjoyment in that setting and, further,
a positive influence on learning. These findings are in strong
agreement with the qualitative and quantitative studies exploring learning in the operating theatre.16–19 Schwind et al.16 found
that students considered the operating theatre to be a positive
environment for learning when there was a friendly atmosphere
in theatre and when there were frequent staff–student interactions. Fernando et al.17 noted similar findings, with 74% of
students surveyed considering that learning was promoted by
having friendly theatre staff. Third-year medical students interviewed by Cloyd et al.18 identified teamwork as an example of
exemplary behavior in the context of medical professionalism.
In the most comprehensive of the qualitative studies, Lyon19
explored learning in the operating theatre by a combination of
group interviews, direct observation, and one-to-one interviews
with both staff and students. As was observed in the current
study, Lyon recorded the familiarization process with the operating theatre environment, which was termed “managing the demands of the working environment.” Although the study did not
specifically explore emotions, excerpts of the student interview
transcripts describe fear and anxiety at potentially violating operating theatre etiquette and protocol. They also reported shame
and humiliation, as noted in the current study. Lyon also recognized the importance of social inclusion of the students in the
operating theatre team, which was termed “managing learning
and the social relations of work in the operating theatre.”
Engagement with the team and inclusion in the “operating
theatre family” underpins the situated learning and communities
of practice educational theories.20 Students start off as peripheral observers in the environment, and as they engage through
social interactions and shared task completion, they assume a
more central role in the team. Pivotal to these theories is the
requirement for the student to feel a sense of belonging for
learning to take place. In the current study, the individual who
reported a failure of social inclusion in the theatre team exhibited the greatest disengagement with the learning process and
expressed the greatest level of dissatisfaction.
MEDICAL STUDENT EMOTIONS IN THE OPERATING THEATRE
The familiarization process with the operating room represents the transition from “outsider” to belonging. The reported
time for this process to take place varied from 1 day to 3 weeks,
the median being 1 week representing five visits to the operating theatre. Familiarization with the physical workspace of
the operating theatre and learning of appropriate conduct in
this setting draws on the social cognitive theory of learning. In
this model, the environment has caused a modification of the
learners’ behavior.
There are a number of potential implications for policy
and practice, mindful of the small scale of the current work.
Nonetheless, the results of this study indicate that learning in
the operating theatre may be enhanced by the following:
1. Ensuring that the student operating theatre curriculum is defined explicitly. The management of learners’ expectations is
an important consideration here. Learning about theatre conduct and familiarization with the theatre environment need to
be spelled out as objectives underpinning all other learning
goals in the theatre.
2. Having students familiarize themselves with the patients
prior to induction of anesthesia so that there is an emotional
connection between student and patient.
3. Providing orientation to the students about the physical
workspace of the operating theatre. This should comprise
an introductory lecture or online learning package such as
commercially available virtual theatre software followed by
a “meet and greet” by the theatre team in the same theatre as
the student will be based subsequently.
4. Waiting for students to learn about and adjust to the physical environment of the operating theatre before expecting
them to learn about the core knowledge curriculum. Exposure to this environment at an early point in medical school
may help reduce anxiety levels and foster successful learning
encounters.
5. Providing orientation and education for faculty and theatre
staff. It is clear from the current study that addressing only
the learners’ concerns will not necessarily effect a change
in practice on the part of the theatre team, both medical
and nonmedical. A dedicated teaching program for how to
manage the learners and the learning environment should be
administered to the theatre team with an emphasis on the
importance of social inclusion. It needs to be made clear
to the theatre team that social inclusion is integral to the
learning journey for the students and that this study identified
that social inclusion was a powerful predictor of enjoyment.
CONCLUSIONS
The principal study findings were that medical students experienced predominantly negative emotions when initially placed
in the operating theatre environment. These emotions were considered a barrier to learning for six of nine participants. There
was a period of familiarization that centered around learning
about conduct in the physical workspace of the operating the-
119
atre and incorporation into the theatre team. This process was
cognizant of the situated learning and the communities of practice models. Feeling included was a powerful predictor of reported enjoyment and was a prerequisite for learning for most
participants.
Future Directions
The current study and the majority of the literature relating
to learning in the operating theatre environment have focused
upon the student perspective. A number of unanswered questions about learning in the operating theatre that could form the
basis of future study remain. What emotions do surgeons, anesthetists, theatre nurses, and practitioners perceive when faced
with medical students? If levels of emotions were quantified
using a scoring scale, do they change in teachers and learners over time? Does a faculty intervention to promote student
engagement influence student learning? Does explicitly defining the theatre curriculum and managing students’ expectations
influence learning?
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