Professional Role of the Operating Room Nurse
The operating room is a technical and complex environment (Bull & FitzGerald, 2006) where patients are exposed to a range of hazards (Anderson, Davis, Hanna, & Vincent, 2013; Nilsson et al., 2016), and it is the operating room nurse's responsibility to maintain and protect the patient's safety by preventing injuries and complications (Alfredsdottir & Bjornsdottir, 2008; Blomberg, Bisholt, Nilsson, & Lindwall, 2015). Operating room nursing entails the ability to see and understand patients as unique human beings, with technical proficiency, as well as medical and procedural knowledge (Bull & FitzGerald, 2006; Gillespie & Hamlin, 2009; Sørensen, Olsen, Tewes, & Uhrenfeldt, 2014). The technical nature of the operating room and the many dimensions of operating room nursing care make it particularly complicated; being skilled and adept on machinery and equipment, while simultaneously viewing and understanding patients as human beings, demands an ability to interact with technology and holistic nursing care. This interaction is important because being technically unskilled or insecure or lacking interest in patients may affect the nurse's ability to work and collaborate with other staff (Sørensen et al., 2014). Comparable settings have been described in other nursing contexts; a still relevant study by Almerud, Alapack, Fridlund, and Ekebergh (2008) of nursing within an intensive care unit refers to the necessity of interpersonal, as well as technical, expertise. Results revealed that insecurity about machines could bring feelings of incompetence (Almerud, Alapack, Fridlund, & Ekebergh, 2008).
Clinical Learning Environment Within the Operating Room Department
The operating room nursing program in Sweden is a 1-year postregistration master's degree education at the university where expected learning outcomes are constructed around the description of competencies described by the Swedish Society of Nursing, the Swedish Operating Room Nurses Association, the Swedish Higher Education Act, and the Swedish Higher Education Authority. The program consists of theoretical and practical learning activities, including several weeks of placements in the clinical setting, during which the students have an opportunity to apply learned theoretical knowledge and practice operating room nursing skills being supervised by an experience operating room nurse (Baxter, 2007; Bolander Laksov, Lonka, & Josephson, 2008). The clinical learning at the operating room department is particularly important given that in Sweden, only nurses with specialization work there and many of the RNs have never been in an operating room department before in their earlier clinical placements or nursing careers. Studies show that presence of undergraduate nurses in the operating room setting during clinical education is limited (Bull & FitzGerald, 2006; Callaghan, 2011). This may lead to an uncertainty of the perioperative nursing students' own perception of their existing nursing competence even though they often are experienced nurses before specialization, as shown in the study by Farnell and Dawson (2006) describing similar experiences of experienced nurses new to critical care.
Studies investigating how operating room nursing students perceive the clinical learning environment are lacking. However, studies including undergraduate nursing students and medical students point to barriers and challenges to learning within the operating room context. In a study involving undergraduate nursing students, participants described feeling overcome by the skills, knowledge, and technical understanding prerequisite to practice. Furthermore, they perceived the role of the operating room nurse to be inflexible and medically dominated (Callaghan, 2011).
Other studies have found that undergraduate nursing students perceived the operating room as a stressful environment and have negative experiences relating to a lack of staff engaged in teaching and learning, a lack of time, fast pace, and a stressful climate (Meyer et al., 2016; Silén-Lipponen et al., 2004). In a study by Bowrey and Kidd (2014), medical students' emotions about exposure to the theater were initially negative, with six of nine students experiencing anxiety levels so high that they were disadvantageous to their learning. Further on, the emotions changed to predominantly positive, except for two participants who experienced negative feelings due to social exclusion. The authors conclude by emphasizing the importance of including students into the theater community of practice.
In a study by Lyon (2003), undergraduate medical students attending the surgical department similarly found the operating department to be a challenging place to learn. The main finding was described as the theme: Managing to Learn in the Operating Theater, including the domains “managing learning and the social relations of work in the operating theater” and “managing the educational tasks, determining the learning objectives and relevance.” The themes contained descriptions of students feeling conscious about using their time in the theater efficiently, noticing the number of other learners, sensing the emotional climate, and having to negotiate social relations to earn opportunities to “play as a legitimate learner at the table…and participate in the community” (Lyon, 2003, p. 684).
The significance of social relations and psychosocial interactions in the students' clinical learning environment, as described in the first published empirical qualitative study by Lyon (2003), is similar to the result of a concept analysis on clinical learning environments by Flott and Linden (2016) that showed four main attributes described as influential on student learning—physical space, the psychosocial and interaction factors, the organizational culture, and the teaching and learning components. One key factor in described in all four attributes is the feeling of belongingness, the supervisor's ability to make the student feel this in the learning environment.
As Niewolny and Wilson (2009) recounted, the notion of learning as a process of social interaction is embedded in numerous learning theories, such as social learning theory (Bandura, 1977), situated cognition (Lave, 1988), transformative learning (Mezirow, 1991), and social constructivism (Illeris, 2007). Theories on the social aspects of learning are similar to behaviorism and cognitive theories, where learning is viewed as an internal or psychological process (Niewolny & Wilson, 2009). Given sociocultural learning theories, one of the goals of learning is for the learner to become a member of the practicing community (Brown, Collins, & Duguid, 1989). Sociocultural factors within the clinical learning environment have been found to influence nursing students learning outcomes in clinical education (Jessee, 2016).
Professional socialization and enculturation within medical and health educational programs are increasingly being recognized as important to meet requirements within the health care systems (Gonzalo, Thompson, Haidet, Mann, & Wolpaw, 2017; Kaufman & Mann, 2013). Authors have argued the need for authentic student roles (Gonzalo et al. 2017), learning through participation in authentic activities (Manninen, Welin Henriksson, Scheja, & Silén, 2013) and investigations into “authentic learning embedded within professional practice” (Webster-Wright, 2009, p. 713).
Yardley, Teunissen, and Dornan (2012) emphasized that when designing experiential learning interventions, it is fundamental to consider the context and the potential and opportunities for authentic practice-based experiences, as it is these that trigger learning. This is supported by the study results of Weeks, Clochesy, Hutton, and Moseley (2013), who found nursing students' cognitive learning and conceptual and calculation competence in medical dosage calculation problem-solving skills was supported more by exposure to authentic learning environments compared to traditional didactic methods. Swartz (2016) referred to Jenkins (2009), who argued that students learning within participatory cultures and engaging in authentic activities develop “portable skills,” such as abilities to apply judgment to distinguish reliable information from unreliable, ability to synthesize and recognize patterns in unfamiliar contexts, and flexibility to work across boundaries to generate innovative solutions. For nursing students to develop into leaders and professionals who are capable of functioning in the “messiness” of real-life situations and challenges in the clinical arena” (Swartz, 2016 p. 405), these portable skills are much needed (Swartz, 2016).
Work in the operating room is often irregular in nature, and this limits a prepared teaching program (Lyon, 2003; Radford & Hunt, 1999). Previous research of learning within the operating room department has emphasized the importance of including students into the community of practice in the operating room department. To support operating room nursing students in reaching the intended learning outcomes, as well as becoming capable practitioners, there is a need for recognizing the complexity of the learning process in clinical education and to examine the context and learning environment, as these have a great influence on learning. This study aimed to examine newly graduated operation room nurses' perception of the learning environment in the clinical setting of the operation room specialist nursing program.