Discussion
The operating theatre as a learning environment is unique that it is a
high-risk environment and shaped heavily by human factors. Modern
surgical training curriculum often incorporates skills lab and
simulations to navigate this. However, non-technical skills such as team
work, leadership and situation awareness are difficult to address in a
simulated environment (12). Compounded by the lack of suitable analogous
surgical models for the simulation of procedures, the operating theatre
remains the predominant learning environment for trainees to acquire
both technical and non-technical skills despite recent technological
advances. Therefore, it is imperative that the theatre learning
environment is evaluated regularly to address its deficiencies as
perceived by trainees themselves in order to enhance learner
performance.
In our study, items were taken from the widely used Cassar Surgical
Theatre Educational Environment Measure and discussed in a focus group
of higher surgical trainees. The Cassar instrument has been adapted and
validated in various studies aimed at different populations (13–15). In
these studies the subscale structure of the instrument had largely
preserved in their factor analysis, hence it is not surprising that the
participants in our focus group agreed on the three existing subscales
in being the main constructs in the theatre learning environment.
Similarly, like the aforementioned studies, population and
discipline-specific factors had precipitated the collapse of items in
our version of the instrument which aimed at higher surgical trainees.
“I am too busy doing other work to go to theatre ” was removed
as trainees felt the item was not applicable to them because higher
surgical trainees will have protected theatre sessions incorporated into
their job plan. “I am so stressed in theatre that I do not learn
as much as I could ” was removed as trainees felt that this statement
did not identify any elements in the learning environment as the source
of stress and could be interpreted as trainees not coping with the
program.
The CVI and Cronbach’s α both indicate that our instrument has a high
content validity and internal consistency. Two items were excluded from
the instrument because they did not reach a critical CVI after being
reviewed by the panel of higher surgical trainees. It is surprising that
item “The theatre staff are friendly ” did not reach the
critical CVI as theatre staff personalities has been found to be a
consistent theme in influencing the theatre atmosphere and hence, the
learning environment (8,14). This could be because the item was
perceived to be redundant as there are already other items addressing
theatre nursing staff and anesthetists in the instrument. The
friendliness of theatre staff was also accessed by item “I feel
part of a team in theatre ”, therefore the removed item was not
assessing a unique element and hence would not reduce the overall scope
of the instrument. Item “I can comfortably express my preference
to if music is played in theatre ” had the lowest CVI of 0.43 in both
higher surgical trainee panel and consultant trainer panel.
Interestingly, this was an extra item added upon discussion with the
focus group in the initial stage of the study. Participants felt that
music improves the calmness and atmosphere of the theatre. Current
literature supports this view but suggested that music can also be
distracting and cause impaired communications (16). Studies have also
shown that surgeons were the more empowered group amongst theatre staff
when it comes to choosing music (17). However, the importance of this
was not recognized by either panel in our study.
Cronbach’s α of the final 27-item instrument was 0.88. This is
comparable to similar established instruments, such as the Surgical
Theatre Educational Environment Measure (0.877) (9) and the Postgraduate
Hospital Education Environment Measure (0.899) (18). When looking at
individual Cronbach’s α in the three subscales, these values are also in
range with studies that had broken down the Postgraduate Hospital
Education Environment Measure into individual subscales (19).
Although the aim of our study is to develop and validate a feedback
instrument, the initial responses from higher surgical trainees were
also analysed in order to provide a current view of the theatre learning
environment. The mean score of our study population (77.2%) was similar
to the mean score of the Surgical Theatre Educational Environment
Measure (74.4%) (9). Similarly, operating opportunities had the lowest
subscale score compared to the other subscales. This may reflect that
naturally, opportunities for trainees to operate is the most challenging
aspect to optimise in the learning environment as this is dependent on
multiple factors such as variety of cases and time pressure.
A conductive learning environment has been shown to be associated with
improved learner performances and help develop the trainees’ surgical
confidence (20). By regularly evaluating how trainees perceive their
training experiences in the operating theatre, programs can identify
areas that needed to be improved on to ensure successful training. The
limitation of our instrument lies within the validation process as only
local higher surgical trainees were involved and thus could incur a
systemic selection bias. Factors and items perceived to be important
could be population-specific, making the instrument only applicable to
surgical training programs with similar curriculum structure and work
culture. This is particularly relevant in the United Kingdom with the
introduction of the revised curriculum in August 2020, as surgical
training across sub-specialties have been largely unified with Generic
Professional Capabilities and Capabilities in Practice. Nonetheless, the
transparent development and validation process depicted in our study can
be easily adapted by other institutions or specialty training programs,
thereby creating feedback instrument that is targeted at clinical
learners at different level and the wider clinical learning environment.