The Journal of Continuing Education in Nursing

Original Article 

Operating Room Nurses' Perceptions of the Clinical Learning Environment: A Survey Study

Marie-Therese Crafoord, RN, MSc; Janet Mattsson, RN, PhD; Ann-Mari Fagerdahl, RN, PhD

Abstract

Background:

Authors commonly agree that the clinical learning environment significantly affects student learning. Studies of how operating room nurses perceive the clinical learning environment during their specialist studies are sparse.

Method:

This study aimed to examine newly graduated operating room nurses' perceptions of the clinical learning environment during their specialist education. Fifty newly graduated operating room nurses answered a questionnaire gaging their perceptions of clinical education.

Results:

Most participants perceived the clinical learning environment as good and highly associated with the supervisor's ability to supervise, enjoy supervision, and show interest in the participants' degree project. The management at the clinical setting, which was perceived to emphasize the importance of supervision, time allocated especially for supervision, and perceived cooperation between the University and hospital, also had an impact.

Conclusion:

Social interactions and structures within the operating room affect how the clinical learning environment is perceived.

J Contin Educ Nurs. 2018;49(9):416–423.

Abstract

Background:

Authors commonly agree that the clinical learning environment significantly affects student learning. Studies of how operating room nurses perceive the clinical learning environment during their specialist studies are sparse.

Method:

This study aimed to examine newly graduated operating room nurses' perceptions of the clinical learning environment during their specialist education. Fifty newly graduated operating room nurses answered a questionnaire gaging their perceptions of clinical education.

Results:

Most participants perceived the clinical learning environment as good and highly associated with the supervisor's ability to supervise, enjoy supervision, and show interest in the participants' degree project. The management at the clinical setting, which was perceived to emphasize the importance of supervision, time allocated especially for supervision, and perceived cooperation between the University and hospital, also had an impact.

Conclusion:

Social interactions and structures within the operating room affect how the clinical learning environment is perceived.

J Contin Educ Nurs. 2018;49(9):416–423.

Investigations of operating room nursing students' experience of the clinical learning environment are limited. However, studies involving undergraduate nursing students and medical students indicate that the operating room is perceived as a challenging and stressful place in which to learn (Bowrey & Kidd, 2014; Callaghan, 2011; Lyon, 2003; Meyer, Van Schalkwyk, & Prakaschandra, 2016; Silén-Lipponen, Tossavainen, Turunen, & Smith, 2004). Learning within a clinical context is profoundly influenced by the learning environment (Babenko-Mould & Laschinger, 2014; Benner & Wrubel, 1982; Levett-Jones & Lathlean, 2009) and the necessity of an excellent clinical learning environment for nursing student learning has been established by several authors (Jessee, 2016). The classic work of Cowman (1998) stresses the importance of exploring learning environments from the perceptions of students and described students' learning approaches as responses to factors in the context rather than being due to inherent characteristics.

Background

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).

Authenticity

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.

Method

Design

This study is an explorative cross-sectional study design with a quantitative approach.

Participants

A call for participation in the study was sent out in spring 2015 to all operating room nurses who graduated in summer 2014 from all five universities in Sweden that were offering perioperative nursing education at that time.

Data Collection

An envelope was sent to all eligible participants with an information sheet regarding the study, the questionnaire, and a prestamped envelope for return of the questionnaire. A reminder was sent to nonresponders after approximately 1 month.

The instrument used in this study was a questionnaire on clinical supervision for nursing education created by Kauffeldt and Velander-Sundin (2009) modified and adapted to operation room nursing education by Lannér and Teledahl (2011). The questionnaire assesses supervision in clinical education, divided into three parts and consisting of 40 questions focusing on the clinical supervision process and learning environment in the clinical setting. The participants rate their questionnaire answers using a 4-item Likert scale (ranging from 1 = not at all, 2 = to some extent, 3 = to a large extent, and 4 = to a considerable extent). One of the three parts of the questionnaire is exclusively focusing on learning environment in the clinical setting, and data from that part are used for analysis in this study. The areas focusing on the learning environment in the questionnaire were physical learning environment and resources, the importance of the supervisor, and the importance of the management of the clinical setting.

Data Analysis

Data were on nominal and ordinal levels and analyzed using SPSS® version 23. The nominal data were presented descriptively. The variables, measured using a 4-item Likert scale, were dichotomized as the response options to a large extent and to a very large extent formed the group “large extent,” and not at all and to a small extent formed the group “to some extent.” A significance analysis with the dichotomized variables was performed using Pearson's chi-square test. The significance level for all analyses was set at p < .05.

Ethical Considerations

In the information sheet sent to the eligible participants, it was stated that participation in the study was completely voluntary and confidential. A completed and returned questionnaire was considered to be written consent for participation, as stated in the information sheet.

Extensive discussions were made within the research group at the university regarding ethical considerations. The decision was made that a formal ethical application to an ethical review board was not required because the participants no longer were under any dependency as students given that they all were graduated from the universities and working as registered operation room nurse specialists with sufficient knowledge in the research process. The study followed good scientific practice and ethical principles in accordance with the Helsinki declaration and Swedish Data Protection Act.

Results

A total of 95 nurses were eligible for participation. Five were not possible to contact due to invalid addresses. The total number of respondents was 50, for a response rate of 56%.

The mean age of the participants was 35 years, and they have been working as RNs for in average of 6 years before their specialization. For the majority, the clinical part of their education was located at a university hospital and the mean educational time spent in the clinical setting was 14 weeks, ranging from 9 to 20 weeks (Table 1).

Sociodemographic Characteristics of the Participants (N = 50)

Table 1:

Sociodemographic Characteristics of the Participants (N = 50)

Physical Learning Environment and Resources

The possibility of using the Internet during the clinical education was present for the majority of the participants (90%). However, this did not significantly affect the supervisors' encouragement of searching for and use relevant research in clinical supervision. Nevertheless, all the participants who did not have any access to the Internet (n = 5) stated that they had no or little encouragement of searching for and use relevant research by their supervisors during clinical education. The majority reported little or no availability of relevant study literature at the clinical setting.

Importance of the Supervisor to the Students' Perception of a Good Clinical Learning Environment

In general, the participants perceived the clinical learning environment as being good to a large or very large extent (86%). One person rated the clinical learning environment as poor. A perceived good clinical learning environment was highly associated with the supervisor, and the supervisors' perceived ability to supervise, enjoy supervision, and interest in the participants' degree project.

Influence of Management

Ten percent of the participants perceived that managers emphasized the importance of supervision to a large extent. Allocated time for supervision was perceived to be present to a higher degree for those who did (p = .04). Management in the clinical setting that emphasized the importance of supervision to a large extent was also associated with a higher degree of supervision incorporating reflection, theoretical, and scientific perspectives, as well as feedback and encouragement in critical thinking (Table 2). The cooperation between the hospital and the university was found to affect the students' perception of the clinical learning environment, as was allocated time for clinical supervision. Those who reported that the university and hospital cooperated to a large or very large extent more frequently perceived the clinical learning environment as good or very good (p = .02) (Table 3).

Statistically Significant Items Relevant to “Management in the Clinical Setting that Emphasize the Importance of Supervision” (N = 50)

Table 2:

Statistically Significant Items Relevant to “Management in the Clinical Setting that Emphasize the Importance of Supervision” (N = 50)

Statistically Significant Items Relevant to the Question “To What Extent Did You Perceive Your Clinical Placement as a Good Clinical Learning Environment?” (N = 50)

Table 3:

Statistically Significant Items Relevant to the Question “To What Extent Did You Perceive Your Clinical Placement as a Good Clinical Learning Environment?” (N = 50)

Discussion

Physical Learning Environment and Resources

Although more than half of the participants reported being at a university hospital, nearly all reported little or no available relevant literature in the clinical setting. However, 90% had access to the Internet. Specialist nurses need to keep up with the latest research to practice according to the best available knowledge, and this may be more difficult if the physical resources are lacking. Considering that many operating room nurses are pressured for time and have a heavy workload, it may be challenging for them to access the hospital library during working hours. Operating room nurses who supervise students may find that a student will benefit from reading about a particular topic after or in preparation for a procedure, for instance, and will suggest this by having close access to a collection of relevant literature on site. Students also benefit from having the possibility to read about a task or procedure near to the event taking place and having a dialogue with the supervisor that is informed by the experience, as well as by theory.

Importance of the Supervisor to the Students' Perception of a Good Clinical Learning Environment

The results point to the importance of the relationship to the supervisor for the students' perception of the learning environment. This supports the results by Papastavrou, Lambrinou, Tsangari, Saarikoski, and Leino-Kilpi (2010) and Saarikoski and Leino-Kilpi (2002), who found that a good student–mentor relationship is an essential component of a good clinical learning environment. Further, this connects to the results of Lyon (2003) and Bowrey and Kidd (2014) in the validation of the students' dependence on relations to learn in the theater. However, Nyhagen and Strøm (2016) point out that postgraduate and undergraduate students may differ in how they view and value the relationship with their supervisors and what type of learning opportunities they perceive as important in clinical education. In their study, postgraduate critical care nurses—as opposed to the results of studies with undergraduate students—emphasized that it was not a social relation that they sought, but rather a professional one.

Professional Role of the Operation Room Nurse

The many dimensions of operating room nursing and the complexity of the operating room nursing role (Sørensen et al., 2014) puts high demands on the operating room nursing student in clinical education to learn effectively. Therefore, providing the right support to the student is vital. Mattsson, Forsner, and Bolander Laksov (2014) pointed out that due to the high level of influence the supervisor exerts on the students learning, it is important that the supervisor manages the pedagogical learning process so that it becomes clear and purposeful. Further, Mattsson et al. (2014) stated that the ability to do this is related to both the quality of the nursing care and pedagogical competence.

Nursing practice in highly technical environments is complex and requires deep and comprehensive understanding of theoretical medical and nursing knowledge, as well as technical skills and the ability to continuously learn new technologies. In addition, it requires maturity in caring to translate into the ability to maintain the view of patient as a whole and unique person. The supervisor is an important person who influences the operating room nursing students' experience of the clinical learning environment. The supervisor can facilitate student learning that integrates theoretical knowledge and technical nursing skills while maintaining a focus on the individual patient's care needs (Mattsson et al., 2014).

Impact of Management

The results of this study indicate that when the management is perceived to emphasize the importance of supervision, more allocated time for this is perceived to take place and several elements that are of great importance in supervision of a higher academic level are reported to be present. It has been argued that the value of theories around the social aspects of learning is moderated if they are conceptualized in a manner that refrains from exploring the power relations that are essential to completely capture adult learning as a sociocultural experience (Niewolny & Wilson, 2009).

The often cited work from Lingard, Reznick, Espin, Regehr, and DeVito (2002) defines communication in the operating room as reflecting strategies for achieving goals while simultaneously minimizing tension and maintaining social cohesion. The authors described how interprofessional communication patterns associated with tension in the operating room is spread to novices, who respond by altering their behavior to either mimic their teacher or withdrawing from communication. The fact that novices were never seen to intervene or redirect within a situation of tension was interpreted by the authors as a sign of the vulnerable status of the novice. The study showed how communication patterns influenced the socialization of novices in the operating room and as language patterns are subject to social, political, economic, and cultural influences, the patterns are not static but instead reflect the dynamic social entity of the operating room team.

Conclusion

The results of this study add further to what has been concluded about the supervisors' impact on the students' experience of the clinical learning environment. Moreover, it shows the importance of supporting and strengthening supervisors into competent and good pedagogics. Finally, given previous research, the results invite further investigation into how social interactions and structures within the operating theater can be developed to further support learning opportunities and strengthen the quality of the clinical education within the operating room nursing program.

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Sociodemographic Characteristics of the Participants (N = 50)

CharacteristicValue
Mean age (years)34.7 (range = 26–53)
Gender (n)
  Female45 (90%)
  Male5 (10%)
Mean time as an RN before operating room nurse specialist education (years)5.9 (range = 0–15)
Mean educational time in clinical setting (weeks)14.2 (range = 9–20)
Clinical setting during education (n)
  University hospital28 (56%)
  Regional hospital19 (38%)
  Rural hospital2 (4%)
  Private hospital0
  Missing value1 (2%)

Statistically Significant Items Relevant to “Management in the Clinical Setting that Emphasize the Importance of Supervision” (N = 50)

ItemSome Extent (n)Large Extent (n)Missing (n)p Value
To what extent did your supervisor/supervisors use reflection as a method in clinical supervision?1.05
  Some extent177
  Large extent1114
To what extent did you receive continuous feedback from your supervisor/supervisors during clinical supervision?2.001
  Some extent80
  Large extent2020
To what extent did your supervisor/supervisors encourage critical thinking in clinical supervision?1.01
  Some extent143
  Large extent1418
To what extent did your supervisor/supervisors encourage you to search and use current research during the clinical supervision?1.02
  Some extent2715
  Large extent16
To what extent did your supervisor/supervisors focus on theoretical perspectives (e.g., theories, models, manuals, general care plans) during the clinical supervision?1.05
  Some extent2615
  Large extent26

Statistically Significant Items Relevant to the Question “To What Extent Did You Perceive Your Clinical Placement as a Good Clinical Learning Environment?” (N = 50)

ItemSome Extent (n)Large Extent (n)p Value
To what extent do you perceive your supervisor's/supervisors' ability to supervise in general?< .001
  Good40
  Very good343
To what extent do you perceive it as your supervisor/supervisors found joy in supervising?< .001
  Some extent64
  Large extent139
To what extent did you perceive that your supervisor/supervisors were interested in your project work/master's thesis included in the education?.05
  Some extent230
  Large extent513
To what extent did you perceive that your supervisor/supervisors cooperated with the university teacher regarding assessment and evaluation of your study results?.01
  Some extent721
  Large extent022
Authors

Ms. Crafoord is Operating Room Nurse and Doctoral Student, Department of Neurobiology, Care Sciences and Society, and Dr. Fagerdahl is Operating Room Nurse, Research, and Lecturer, Wound Centre, Södersjukhuset, Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm; Dr. Mattsson is Intensive Care Nurse and Researcher, Department of Learning, Informatics, Management and Ethics, and Lecturer, Department of Health Sciences, The Swedish Red Cross University College, Stockholm, Sweden.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Ann-Mari Fagerdahl, RN, PhD, Operating Room Nurse, Research, and Lecturer, Wound Centre, Södersjukhuset, Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden S-118 83; e-mail: ann-mari.fagerdahl@ki.se.

Received: January 08, 2018
Accepted: May 02, 2018

10.3928/00220124-20180813-07

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