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.