Department of Surgery, Shalamar Medical and Dental College, Lahore, Pakistan
Mr Talat Waseem FRCS Eng, FACS,Consultant Surgeon Shalamar Medical and Dental College, Lahore
Operating Room-based student learning is multifactorial and has traditionally been suboptimal.
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Operating Room-based student learning is multifactorial and has traditionally been suboptimal. Medical students’ perspective about OR-based learning differs from a surgical resident's perspective, and many factors have been previously identified to affect students' OR-based learning. Recently, a growing body of literature has emerged and has been collated to emphasize at least five domains that govern the student learning experience within the OR setting. These include the quality of the structured learning process, organizational support, psychosocial perspectives, and factors related to teachers and the student. Mini-Surgical Theater Educational Experience Measure (STEEM) or mini-STEEM was previously designed to evaluate students' experience; however, in light of the evolving body of literature, mini-STEEM may no longer be a content valid instrument. |
The dynamic environment within the Operating Room (OR) provides a real-life venue for medical students’ learning
Nagraj et al. previously proposed the instrument ‘mini-STEEM’ to assess the quality of student learning within the OR environment, which is an abbreviated form of Kevin Cassar’s Surgical Theater Educational Environment Measure
In light of an improved understanding of OR-based learning and multiple recent literature reviews that identify many essential domains of student learning within the OR setting, there is a clear need for re-validation of the mini-STEEM. This study aims to assess the content validity, reliability, and construct validity of mini-STEEM.
Following ethical approval from the local institutional review, a board study was conducted, as shown in Figure 1. In the first phase, we relied on the previously published literature evidence
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(Structured Course /Lesson Planning, Content Selection, Delivery, Assessment & Administration) |
Structured or Opportunistic OR learning |
No representative Item |
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0 |
Design and Communication of Learning Objectives for OR learning |
No representative Item |
0 |
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Clarity of Learning Objectives |
No representative Item |
0 |
||
Feasibility of learning objectives to be realistically achievable |
No representative Item |
0 |
||
Synchronization of the learning objectives with rest of the teaching. |
No representative Item |
0 |
||
Importance of Personal Learning Objectives in OR Learning |
No representative Item |
0 |
||
Content Selection, delivery, assessment and their alignment to essential aspects of graduate learning |
Before the operation my trainer discusses the surgical technique planned The elective operating list has the right case mix to suit my training The variety of emergency cases gives me the appropriate exposure On this unit the types of operations performed are too complex for my level* |
0.92 0.73 0.75 0.81 |
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Optimal student-teacher interaction & opportunities for equal participation |
I get enough opportunity to assist There are enough theatre sessions per week for me to gain the appropriate experience The anaesthetists put pressure on my trainer to operate himself to reduce anaesthetic time* I am too busy doing other work to go to theatre* When I am in theatre, there is nobody to cover the ward* |
0.65 0.76 0.63 0.51 0.42 |
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(Educator Related Factors) |
Interest of educator |
My trainer is enthusiastic about teaching |
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0.95 |
Importance of the educator's behavior and attitude |
No representative Item |
0 |
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Competency of educator |
No representative Item |
0 |
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Importance of teaching style |
No representative Item |
0 |
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Importance of teacher’s preparedness |
No representative Item |
0 |
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Significance of OR orientation session. |
No representative Item |
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0 |
Importance of environmental readiness |
The atmosphere in theatre is pleasant |
0.87 |
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Synchronization simulation / Lab activities with OR lessons |
No representative Item |
0 |
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Importance of adequate visualization in student learning |
No representative Item |
0 |
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Impact of anxiety in the OR environment |
No representative Item |
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0 |
Effect of fear, intimidation, discrimination or victimization in OR learning environment |
I feel discriminated against in theatre because of my sex* I feel discriminated against in theatre because of my race* |
0.83 0.81 |
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Impact of feeling welcome in OR |
The theatre staff are friendly |
0.88 |
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Ability to self-regulate learning in OR |
No representative Item |
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0 |
Impact of student’s motivation |
No representative Item |
0 |
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Impact of self confidence |
No representative Item |
0 |
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Student’s Prior Knowledge & Pre-lesson self-review of reading material |
No representative Item |
0 |
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Student's readiness to participate |
No representative Item |
0 |
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Student’s Focus on Practice of skills |
No representative Item |
0 |
In phase 2, the scale was content validated by 8 experts, and the I-CVI estimation was done as described previously. The qualitative data regarding the mini-STEEM items was subjected to thematic analysis.
The mini-STEEM scale was piloted among 202 students. The mean item scores and their respective SD has been described in Table 2. Exploratory factor analysis (Principal Component Analysis) was done to check for the construct validity, and Cronbach alpha estimation was done to evaluate the reliability of the constructs (Table 3).
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My trainer is enthusiastic about teaching. |
202 |
1.0 |
5.0 |
2.327 |
1.1251 |
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The theatre staff are friendly. |
202 |
1.0 |
5.0 |
2.535 |
1.2303 |
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There are enough theatre sessions per week for me to gain the appropriate experience. |
202 |
1.0 |
5.0 |
2.866 |
1.3147 |
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Before the operation my trainer discusses the surgical Technique planned. |
202 |
1.0 |
5.0 |
2.782 |
1.1642 |
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The elective operating list has the right case mix to suit my training. |
200 |
1.0 |
5.0 |
2.770 |
1.0830 |
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The variety of emergency cases gives me the appropriate exposure. |
202 |
1.0 |
5.0 |
2.896 |
1.2634 |
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I get enough opportunity to assist. |
202 |
3.0 |
5.0 |
4.213 |
.7722 |
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On this unit the types of operations performed are too complex for my level.* |
202 |
3.0 |
5.0 |
3.851 |
.7037 |
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The anaesthetists put pressure on my trainer to operate himself to reduce anaesthetic time* |
202 |
3.0 |
5.0 |
3.955 |
.8364 |
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I feel discriminated against in theatre because of my sex* |
202 |
1.0 |
5.0 |
3.663 |
1.3985 |
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I feel discriminated against in theatre because of my race* |
202 |
1.0 |
5.0 |
4.069 |
1.3696 |
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I am too busy doing other work to go to theatre* |
202 |
3.0 |
5.0 |
4.158 |
.7562 |
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The atmosphere in theatre is pleasant. |
202 |
3.0 |
5.0 |
3.995 |
.7498 |
Total |
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44.082 |
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Component |
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1 |
2 |
3 |
4 |
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6. The variety of emergency cases gives me the appropriate exposure. |
.740 |
.224 |
-.073 |
.116 |
.737 |
.739 |
5 |
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3. There are enough theatre sessions per week for me to gain the appropriate experience. |
.713 |
-.044 |
.056 |
-.002 |
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5. The elective operating list has the right case mix to suit my training. |
.671 |
-.117 |
-.018 |
-.132 |
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4. Before the operation my trainer discusses the surgical Technique planned. |
.650 |
-.047 |
-.091 |
.048 |
||||
1. My trainer is enthusiastic about teaching. |
.593 |
-.562 |
-.099 |
-.094 |
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11. I feel discriminated against in theatre because of my race. |
.126 |
.844 |
-.055 |
.060 |
0.696 |
0.697 |
2 |
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10. I feel discriminated against in theatre because of my sex. |
-.005 |
.813 |
.218 |
-.121 |
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2. The theatre staff are friendly. |
.463 |
-.548 |
.061 |
.043 |
- |
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8. On this unit the types of operations performed are too complex for my level. |
.091 |
.010 |
.780 |
.002 |
.537 |
.539 |
3 |
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9. The anesthetists put pressure on my trainer to operate himself to reduce anesthetic time. |
.039 |
.137 |
.683 |
.239 |
||||
13. The atmosphere in theatre is pleasant. |
-.341 |
-.020 |
.643 |
.010 |
||||
7. I get enough opportunity to assist. |
.183 |
-.105 |
.000 |
.777 |
.255 |
.255 |
2 |
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12. I am too busy doing other work to go to theatre. |
-.211 |
.063 |
.224 |
.683 |
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Extraction Method: Principal Component Analysis. Rotation Method: Varimax with Kaiser Normalization. a. Rotation converged in 5 iterations. |
Kaiser-Meyer-Olkin Measure of Sampling Adequacy..753 Bartlett's Test of SphericityApprox. Chi-Square513.116 df78 Sig..000 |
The statistical analysis was done in SPSS, and SPSS Amos, and Cronbach alpha estimation, and the content validity index were measured as described previously.
In the first phase, the literature evidence was explored, and five basic domains of factors affecting the students' learning experience within the OR were identified as tabulated in Table 1. The corresponding conceptual framework has been described in Figure 2. These domains include structured learning process, quality of faculty and training, psychosocial management, organizational support, and students' ability to self-regulate. Based on these 5 themes, 26 different sub-themes were identified, tabulated in Table 1.
In Phase 2 of this study, mini-STEEM items were content validated by 8 experts. The I-CVI and the corresponding expert analysis of these items have been summarized in Table 1, along with their representative expert quotes.
Based on literature evidence, the experts consider the structured learning process to be one of the most critical factors influencing the quality of overall learning experience within the OR setting. Mini-STEEM has 9 items to assess the structured learning process, concentrating mostly on the process of content selection and quality of student-teacher interaction. However, these items do not determine structured vs. opportunistic learning, the learning objectives' design and their adequate communication to the students.
The structured learning approach provides a framework for students to follow and includes specified preassigned readings, immediate feedback from their tutors following a clinical experience and the use of systematically organized instructional methodologies. This approach is also effective in enforcing the deliberate practice of clinical skills acquisition.
According to one expert, “
For the OR experience to be beneficial, it is of paramount importance that practical learning objectives are formulated and are communicated with the students.The involvement of learners in the formation of learning objectives allows them to recognize the areas where skills need to be acquired. With regard to learning objectives, an expert pointed out that
Moreover, another expert stated that
Furthermore, an expert commented that
And another stating that
Surgical residents and medical students differ not only in their degree of knowledge and experience but also in their responsibilities and expectations from the OR encounter. It is therefore, impracticable to assess their needs and influencing factors on the same scale. As stated by an expert
Regarding the statement, “My trainer is enthusiastic about teaching” from mini-STEEM, one expert agreed that
However, when the subtheme ‘competency of educator’ was questioned, an expert responded that
Another expert observed that
The availability of basic and fundamental technology can have a remarkable impact on
the theater-based learning.
It was highlighted by an expert that the statement ‘the atmosphere in the theatre is pleasant’ is
It was further added that an
Medical students are subjected to a wide array of stimuli within the OR setting which can trigger a range of mixed emotions. Students must face new challenges whilst overcoming their emotions.
According to an expert
And in addition to that
Another expert further stated that
Based on the literature review, it has been seen that students’ attitude and their level of interest and responsiveness determines the drive of the surgeon to teach.
It was stated by an expert that
Regarding mini-STEEM, an expert mentioned that
And
Medical students’ learning experience is unique, differs from a resident's learning perspective, and is multifactorial. Previously, experts in this area have identified and prioritized various intermediary items, which regulate the learning process and quality outcomes. Many factors related to the structured learning process, organization, educator, student, and psychosocial domains determine the quality of overall learning experience in the OR setting. Previously, mini-STEEM, an abbreviated version of STEEM, has been used to assess the OR learning process's quality. However, its content validity has been challenged recently, considering expanding dimensions of the OR learning process.
There is a growing body of literature that directs and indicates the expanding role of a structured learning process despite the difficulties of its implementation within the OR setting. The structured learning process involves careful course planning, delivery process, and assessment involving the psychomotor and affective components apart from the operative learning's cognitive portion. Similarly, educator-related and student-related factors significantly influence the learning process within the OR setting. Teacher's interest, competence, style, and welcoming attitude are independent predictors of quality OR learning. Faculty training in this regard can be pivotal and also provides chances for better student handling within the OR setting. The students' interest, receptive attitude, capacity to self-regulate learning and social handling within the OR can alter the outcomes of the learning process. The organizational support in terms of providing adequate technology and administrative support has additive value. Psychosocial training of the faculty and the students can positively affect the quality of learning process.