Nurse Education in Practice 16 (2016) 217e224

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Nurse Education in Practice

journal homepage: www.elsevier.com/nepr

Undergraduate surgical nursing preparation and guided operating

room experience: A quantitative analysis
Paula Foran a, b, c, *
a
Australian College of Operating Room Nurses (ACORN), Australia
b
School of Medicine, Faculty of Health, Deakin University, Australia
c
School of Nursing and Midwifery, Deakin University, Australia

a r t i c l e i n f o a b s t r a c t

Article history: The aim of this research was to determine if guided operating theatre experience in the undergraduate
Accepted 9 August 2015 nursing curricula enhanced surgical knowledge and understanding of nursing care provided outside this
specialist area in the pre- and post-operative surgical wards.
Keywords: Using quantitative analyses, undergraduate nurses were knowledge tested on areas of pre- and post-
Surgical nursing operative surgical nursing in their final semester of study. As much learning occurs in nurses' first year of
Operating theatre
practice, participants were re-tested again after their Graduate Nurse Program/Preceptorship year. Par-
Workplace learning
ticipants' results were compared to the model of operating room education they had participated in to
Cognitive load theory
determine if there was a relationship between the type of theatre education they experienced (if any)
and their knowledge of surgical ward nursing.
Findings revealed undergraduates nurses receiving guided operating theatre experience had a 76%
pass rate compared to 56% with non-guided or no experience (p < 0.001). Graduates with guided
operating theatre experience as undergraduates or graduate nurses achieved a 100% pass rate compared
to 53% with non-guided or no experience (p < 0.001).
The research informs us that undergraduate nurses achieve greater learning about surgical ward
nursing via guided operating room experience as opposed to surgical ward nursing experience alone.
© 2015 Elsevier Ltd. All rights reserved.

Introduction A conversation ensued. One of the experienced operating

As we sat in the operating suite tearoom the feeling amongst the
gathered staff was one immense sadness. One of us had just read an
article aloud from the daily newspaper. The story reported the
coronial inquest of a 37 year-old mother of three who died from an
inability to breathe following routine elective thyroid surgery.
Hospital staff told the patient she was just panicking as she
struggled for air (Hunt, 2004). Two expert medical witnesses, one
of whom was her surgeon, gave evidence to say that the patient's
death was preventable (Hunt, 2004). An expert witness believed
that, had the stitches in her neck been removed sooner, the pa-
tient's life could have been saved (Hunt, 2004).
* Australian College of Operating Room Nurses, Post Office Box 899, Lyndoch,
South Australia 5351, Australia.
E-mail address: paula.foran@acorn.org.au.
theatre nurses stated that she could not understand why the
stitches in the patient's neck had not been removed. Several very
junior nurses, who were visiting the operating suite for the first
time, seemed shocked at this concept. Noting their surprise,
another senior nurse asked the junior staff if they had been taught
this lifesaving procedure during their surgical nursing preparation.
In unison all the younger nurses replied ‘no’.
As an undergraduate nurse I clearly remember my clinical
placement in the operating suite. I recall observing a thyroidectomy
similar to that of the deceased. During this operation the medical
and nursing staff spent time explaining the possibility of post-
operative bleeding; the importance of vigilant airway and respi-
ratory observations and if deterioration was noted to call a medical
emergency. If the patient became hypoxic this situation must be
rectified by removing the stitches from the skin and muscle layers
of the neck. I was appreciative of this knowledge as I had seen this
question on old final examination papers and then felt more pre-
pared; not only to answer a question on post-operative

http://dx.doi.org/10.1016/j.nepr.2015.08.005
1471-5953/© 2015 Elsevier Ltd. All rights reserved.
218 P. Foran / Nurse Education in Practice 16 (2016) 217e224
thyroidectomy care but to perform appropriate lifesaving clinical
measures should this situation arise in one of my patients post-
operatively on the surgical ward.
Unfortunately this death was not isolated, as adverse events in
post-surgical patients are not uncommon. Research conducted in
21 Netherland hospitals reported that surgical adverse events
occurred in 3.6 per cent of patient admissions representing 64.5 per
cent of reported adverse events (Zegers et al., 2011). These surgical
adverse events were severe in nature and 41 per cent were
considered to be preventable (Zegers et al., 2011). Analysis per-
formed in 2007 in the United Kingdom revealed that out of ‘576
reported hospital deaths, 11 per cent were due to serious deterio-
ration of the patients' condition without appropriate recognition or
treatment’ (Lomas and West, 2009). Following a five year Scottish
study looking at 1299 post-operative deaths, Mullen et al. (2012)
concluded that timely, appropriate surgery and high quality pre-
and post-operative care may be the key in preventing deaths in the
first 48 h after surgical procedures.
The National Consensus Statement on essential elements for
recognising and responding to clinical deterioration (Australian
Commission for Safety and Quality in Healthcare, 2010) suggests
that education must be provided to ensure the healthcare work-
force is suitably skilled in knowledge of appropriate patient ob-
servations, identification of clinical deterioration and appropriate
emergency management skills.
As an undergraduate I departed after a six week guided theatre
placement with not only professional direction but a wealth of
knowledge surrounding surgical procedures and possible compli-
cations to be watchful for on the pre- and post-operative surgical
wards; knowledge which, I realised newer nurses may not be aware
of as their opportunities to observe surgery are more limited than
when I was a student.
I became increasingly concerned about the possible missed
education opportunities for undergraduate nurses today and
wondered if a connection could be demonstrated between the
quality of pre- and post-operative surgical nursing care provided
outside the operating theatre and undergraduate nurses' operating
theatre experience during their study. This was the genesis of my
doctoral research.
The aim of this research was not to explore the acquisition of
surgical knowledge for nurses who work in the operating suite, but
rather to explore the knowledge gained from experiential learning
in the operating theatre that supports nursing outside this
specialist area, namely in the pre- and post-operative surgical
wards.
A surgical patient's journey involves a three-part process, which
includes the pre-operative, operative and post-operative phases.
This research considered the potential educational impact on un-
dergraduate and graduate nurses' knowledge of pre- and post-
operative care when the middle piece of the three-part surgical
patient journey was omitted (see Fig. 1).
Literature
Background
The global move from hospital training to university education
saw perioperative/operating theatre clinical experience being
altered from approximately six weeks for every student during the
old hospital-based training era to new models of clinical experience
that differ between university providers.
Since the beginning of this degenerative clinical process,
worldwide concerns have been voiced about possible deterioration
of surgical nursing skills if undergraduates did not actively partic-
ipate in the operative process (Callaghan, 2011; Mott, 2012).
The belief that operating theatre experience is only useful to
nurses working in the operating suite itself, has been refuted over
time (AORN Guidance Statement, 2007; Callaghan, 2011; Sigsby
and Yarandi, 2004).
The question remains, can undergraduate nurses who have been
exposed to ‘non-guided’ operating theatre experience, care for
patients pre- and post-operatively in the surgical wards with the
same level of insight and knowledge as those who have had a
‘guided’ learning experience?
Current experience in Australia (Allanson and Fulbrook, 2010) is
similar to that of U.S.A. (Castelluccio, 2012), Canada (Wade, 2012),
New Zealand (Claridge, 2012), United Kingdom (Lydon and Burke,
2012) ranging from a reintroduction of operating room (OR)
nursing to the core curriculum, or a high dependency subject that
offers OR nursing as an option, or an elective subject comprising of
one week of practical experience, or ad hoc ‘follow through’ visits to
observe a patient's surgery. In many cases students receive no
theatre experience in their undergraduate education and a struc-
tured clinical rotation is rarely offered to undergraduate nurses
(Castelluccio, 2012).
Guided verses non-guided experience
Guided practice, as described by Clark et al. (2012), is where
students have been given explicit instructional guidance and where
the concepts and skills that students need to learn have been
explained. Students in this group would be involved in practical
experience under the direct supervision of an experienced oper-
ating theatre nurse, who was able to explain key concepts and assist
the student in their practical learning experience.
In contrast, non-guided practice refers to practical experience
that the university has not formally arranged for the students, i.e.
an experienced operating theatre nurse has not been allocated to
assist the student. This experience is typical of the ‘follow through’
style of practical where student nurses working in the surgical
wards follow their patient to the operating suite, watch their sur-
gery and recovery and return to the ward to care for their patient.
As these visits are ad hoc operating suite management have no
ability to pre-plan or allocate specific nursing staff to provide
guided supervision for these learners thus generally allowing only
an observation experience with no opportunity to participate in
surgical procedures (Messina et al., 2011; Mott, 2012).
Educational debate regarding the impact of guidance during
teaching has been discussed for over a century (Clark et al., 2012;
Kirschner et al., 2006). On one side are those who believe that all
learners, novice and expert, learn more effectively when they are
asked to interpret information for themselves by providing un-
guided or partially guided learning methods (Clark et al., 2012).
Others believe experts and novices differ, whilst experts are able
to learn effectively with minimal guidance, novice learners require
full explicit instructional guidance to thrive (Kirschner et al., 2006;
Mayer, 2004; Sweller, 1994; Vygotsky, 1978). Those in favour of
guidance suggest that in order for novices to gain knowledge they
will need to be provided with direct instructional guidance (Billett,
2001; Clark et al., 2012; Kirschner et al., 2006).
Cognitive load theory
Cognitive load theory, as described by Sweller (1994) is based on
the hypothesis that the brain uses two types of memory; short
term, which has limited storage capacity, and long term, which has
almost unlimited capacity. Whilst the working memory processes
and stores information for a short time, the aim of learning is to
provide knowledge which will eventually be stored in the long
term memory for later use (Kirschner et al., 2006). In non-guided or
 P. Foran / Nurse Education in Practice 16 (2016) 217e224
Fig. 1. Patient's surgical journey. Figure 1 is my summary of the entire surgical process, which distinguishes the areas of surgical ward nursing and operating theatre nursing.
minimally guided learning heavy demands are placed on the
working memory as it searches to find problem solutions;
Kirschner et al. (2006) suggest that this work does not leave the
working memory free to be available to contribute to the accu-
mulation of knowledge in the long term memory, thus limiting
learning.
Novice learners, such as undergraduate nurses in a foreign
environment like the operating theatre, are of particular concern as
the heavy demands that free exploration of complex environments
place on the working memory may in fact be detrimental to
learning (Clark et al., 2012; Kirschner et al., 2006).
Gap in current literature
American research conducted by Sigsby and Yarandi (2004)
compared the surgical knowledge of undergraduate nurses who
had practical experience in either the operating suite or the medical
and surgical wards. Findings revealed that students who had been
exposed to operating suite experience scored consistently higher
on areas of surgical nursing knowledge than those who had clinical
placements in medical and surgical wards (Sigsby and Yarandi,
2004). A recommendation of Sigsby and Yarandi (2004) research
was to continue research in this area with a larger study comparing
different undergraduate nursing courses with different curricula.
This research addresses a gap in surgical nursing preparation by
exploring the value of differing types of experiential learning in the
operating suite.
Research methods
Given the historical, but nevertheless fairly recent changes in
nursing curriculum worldwide, and the incidents of surgical
adverse events, there was value in investigating the following
research questions.
The two research questions were;
1. Do undergraduate nurses need to be involved in guided oper-
ating suite practical experience in order to achieve skills and
knowledge that support a high standard of nursing care in the
pre- and post-operative surgical wards?
219
2. What are the different models of operating suite education
offered to Australian undergraduate nursing students? Which of
these models yields the best educational outcomes?
This paper presents the quantitative phase of a larger mixed
methods doctoral research project. Ethics approval was granted by
Deakin University.
Research plan

Information was sought from all Australian universities offering
undergraduate nursing inquiring about their learning opportu-
nities in perioperative/OR nursing.

Using a quantitative research design, final year undergraduate
nursing students were involved in data collection testing sur-
gical nursing knowledge.

Nurses following their first year of practice were re-tested, using
the same quantitative tool used for undergraduates, to compare
surgical nursing knowledge from graduating student to grad-
uate nurse.

Comparisons were made between participants' knowledge and
the type of OR experience they participated in.
Australian undergraduate perioperative experience
It was first necessary to determine what types of undergraduate
theatre education was offered nationally in Australia. Contact was
made with all Australian universities that offered undergraduate
nursing via a phone survey. The survey sought information about
the type of operating theatre education offered at their university
(for example, elective, on line, core curriculum); the number of
operating theatre nursing theoretical hours given to students prior
to their clinical placements; whether or not structured or guided
clinical placements were available to all students and if not what
percentage of students accessed guided practical experience, and
the number of hours in a clinical placement.
At the time of data collection 31 Australian universities offered
undergraduate nursing degrees and of these 13 offered specific
operating theatre nursing education. A selection criteria were
220 P. Foran / Nurse Education in Practice 16 (2016) 217e224
developed to assist in selecting appropriate models to invite into
the research. This observed;

Innovation of model e looking for innovation and individuality
in educational delivery such as the on-line learning model,

Geographical location of university e as a national project it
would have been undesirable to have all universities from only
one or two states of Australia,

Differing types of models of OR education e such as elective,
mixed, on-line or core curriculum subjects, Specific OR educa-
tion as opposed to surgical ward nursing education. Some sub-
jects labelled as ‘perioperative’ focused solely on surgical ward
experience and theory, not specifically operating suite.
A letter of invitation, plain language statement and consent
form were sent to the Head of Nursing School in the Faculty of
Nursing at each of the ten chosen universities and of these, six
accepted the invitation to participate.
Models of operating theatre experience
The university model of education referred to the different types
of structured theatre education each university offered. Models
differed in their placement within the curriculum and the mode of
delivery. From the six participating universities there was:

one elective model,

one on-line model,

two core curriculum models,

two mixed models.
Although some universities operating theatre model fell within
the core curricula, students still had to choose between high de-
pendency subjects of which one was theatre nursing. These models
were named ‘mixed models’ as not all students were able to
participate. Students who did not choose the theatre nursing sub-
ject offered at their university made up the fifth model of ‘no
operating theatre education’. Only core curricula models that pro-
vided every student with a theoretical operating theatre nursing
component were labelled as ‘core curriculum’ models (Table 1).
Pattern mix of education
The pattern mix of education related to the different teaching/
learning opportunities incorporated in each model. Included in the
pattern mix were a combination of operating theatre nursing the-
ory (theory); guided practical workplace experience (guided prac-
tice); non-guided practical workplace experience (non-guided
practice), and extra practical experience (extra experience).
Extra experience was recorded where students hours were more
than had been arranged by their university as students had made
personal arrangements with the operating theatre management to
have extra time (Table 2).
Research questionnaire
In order to assess nurses' knowledge, a quantitative measure
needed to be constructed. A 20 point multiple-choice assessment
tool was developed to measure participants' surgical knowledge
relating to; the areas of concerns raised in international literature;
related to areas of practice that were considered essential for all
surgical nurses, and that fell within the national guidelines of
competency expected for surgical nursing practice (Australian
Nursing and Midwifery Council, 2010).
There were four areas of concerns raised in international liter-
ature where it was believed that possible deterioration of surgical
nursing skills may occur if undergraduates were not exposed to
learning in the operating theatre. These areas made up the basis
content of the assessment tool and included;

patient education e four questions on pre-operative patient
education,

pre- and post-operative nursing care e three questions
regarding pre-operative care & eight surrounding post-
operative care,

infection control (asepsis) e two questions regarding infection
control,

post-operative pain management e three questions on acute
post-operative pain management.
The Head of the School of the Nursing Faculty at each of the
participating universities signed consent giving permission to
invite their students to participate. On a voluntary, anonymous
basis, final year nursing students were invited to participate in
the research. Data was collected via a questionnaire. The first
part of the questionnaire collected information on gender, the
number of clinical hours participants spent in the operating
theatre (if any) and if they participated in a perioperative pro-
gram offered at their university. The individual universities
distributed the questionnaires to their own students with
prepaid addressed envelopes for return to the researcher. This
made it possible to tailor the question on curriculum choice
specifically using the actual subject name each student would be
familiar with. The second part of the questionnaire involved the
multiple-choice assessment tool.
There were 332 undergraduate nursing students who partici-
pated in the research and were knowledge tested on areas of pre-
and post-operative nursing. A sample size calculator confirmed a
confidence interval of 5.98 and confidence level of 99%.
Testing was undertaken during the students' final semester of
university studies, prior to the students' final examinations. This
period was chosen to allow all students to have gained as much
practical experience as possible in their three years of education. An
earlier timeframe may have disadvantaged the students who were
not involved in guided or structured programs as many hospital
clinical placements involving ‘follow-through’ visits occur in the
students' final semester.
Validity of assessment tool
Several methods were used to validate the multiple-choice
assessment tool, including focus groups and piloting of the
tool. Prior to construction, it was necessary to confirm two as-
sumptions; the first was that the content of the questions was
essential to surgical ward nurses, and the second was to ensure
that this knowledge could be gained via operating theatre
experience.
To confirm the first assumption, the first focus group was
convened to confirm that the areas of concern identified in the
literature were in fact areas of knowledge that were essential to
surgical ward nursing. This group consisted of ten qualified
experienced registered nurses from surgical wards who all had at
least two years surgical nursing experience and were currently
practising within this speciality. The group were given a list of 20
subject topics that fell within the four areas of concern that had
been identified. The group was asked to comment on whether or
not these subjects were issues of importance for safe surgical
nursing practice. The ensuing discussions saw some topics
removed and others added until a list of 20 topics were developed.
 P. Foran / Nurse Education in Practice 16 (2016) 217e224 221

Table 1
Taxonomy of differing models of specific OR education offered to undergraduate nurses in Australia.

These topics were used in the construction of multi-choice acute hospital setting, namely Nurse Unit Managers, a Deputy
questions. Director of Nursing and an Executive Education Manager, all with
Creswell and Plano Clark (2011) suggest that content validity interests in surgical nursing. Objectives of the group were
can be judged by a panel of expert peers. To facilitate this a explained, namely to assess if the multiple-choice questions were
second focus group was convened to further scrutinise the con- an accurate representation of knowledge needed for safe surgical
tent validity. This group consisted of senior nursing staff from the nursing. The group was in agreement that all questions related to
required knowledge.
The third focus group consisted of 20 senior experienced OR
Table 2 nurse educators who were asked to scrutinise the draft telephone
Possible combinations of pattern mix. survey and the draft assessment tool. The group was asked to
Theory Guided Non-guided Extra complete the assessment tool to ensure that the knowledge
practice practice experience required for surgical ward nursing could be gained through oper-
Nothing (neither theory nor any ating suite experience. The average score for this group was 19 out
form of practice) of a possible 20, confirming the second assumption that the subject
Non-guided practice ✓ matter was well understood by OR nurses, and could be learnt via
Theory ✓ OR experience.
Theory & non-guided practice ✓ ✓
Guided practice ✓
Following the validation process, the assessment tool was
Theory & guided practice ✓ ✓ piloted on 154 undergraduate nursing students for my master
Theory/guided practice & extra ✓ ✓ ✓ research before being used on the doctoral project.
experience
222 P. Foran / Nurse Education in Practice 16 (2016) 217e224
Quantitative data analyses
Statistical comparisons were made between participants'
knowledge and the type of OR experience they participated in.
These included;
Participant score and:

guided verses non-guided practical experience,

pass/fail,

model of education,

pattern mix of education,

time spent in the operating suite.
Quantitative statistical analyses were conducted using SPSS
version 22.0 for Windows (SPSS Inc, Chicago) and XLStatistics 2008.
In the assessment of differences between two groups an indepen-
dent t-test analysis was conducted.
For assessment of differences between more than two inde-
pendent groups, where the assumptions associated with the
application of parametric statistical methodologies were met,
overall differences were identified using a one-way analysis of
variance (ANOVA). As ANOVA is an omnibus test statistic and
cannot provide information on which specific groups were signif-
icantly different from each other, subsequent post-hoc analysis was
conducted using Tukey's Honestly Significant Difference (HSD) test.
Where assumptions were not met, the nonparametric analogue to
the ANOVA, the KruskaleWallis rank test was also used, with
subsequent post-hoc analysis conducted using the ManneWhitney
Mu test. All post-hoc analysis probabilities were adjusted for with
the Bonferroni test.
A Pearson productemoment correlation coefficient was
computed and a linear regression model constructed to make a
comparison between time spent in theatre and participant score.
A common international practice following graduation at the
Bachelor level is for nurses to enrol in a Nurse Residency Pro-
gram or Graduate Nurse Program which provides professional
and educational support for first year nurses (Al-Dossary et al.,
2014; Cubit and Ryan, 2011; Haggerty et al., 2013; Nematollahi
and Isaac, 2013; Rush et al., 2013). These programs close the
gap between a novice and a fully competent independent prac-
ticing nurse (Al-Dossary et al., 2014). A second analysis was
undertaken as clinically relevant competency is not expected at
graduation, but will develop in conjunction with further educa-
tion and guided clinical practice (Stobinski, 2008). There was
therefore value in exploring this assumption as much learning is
achieved during graduate programs as they provide 12 months
of additional education and practical experience. Re-testing
students (using the same assessment tool) after this time pro-
vided a useful further data set to assist in developing a greater
understanding of the long term surgical knowledge of our
graduate nurses.
Findings
Guided verses non-guided practice
The first groups for comparison were those who had been
involved in guided and non-guided practical OR experience.
Undergraduate nurses who were involved in guided practical
experience participated in the following pattern mixes;

theory, guided practice and extra experience;

theory and guided practice,

guided practice.
Undergraduate nursing students who were involved in non-
guided practical experience participated in the pattern mixes of;

theory and non-guided practice,

theory,

non-guided practice,

and nothing (neither theory nor any form of practice).
An independent sample t-test was utilised to compare the dif-
ferences between scores of those who had been exposed to guided
and non-guided practical experience. The t-test analysis revealed a
p value of <0.001. From these findings the conclusion was drawn
that there is a statistically significant difference in the knowledge
levels between the two groups (t ¼ 4.743; p < 0.001). It was
concluded that students who have been exposed to guided oper-
ating theatre experience had achieved a higher score on areas of
surgical ward nursing.
The concept of pass/fail is important as it indicates the partici-
pants' ability to not only progress further academically, but also
determines their ability of the gain nursing registration and to
practice as a registered nurse. Results revealed a statistical signifi-
cance between pass/fail and guided and non-guided experience
(t ¼ 4.304 p < 0.001). The pass rate was set at ten out of twenty.
Model of education
A one-way ANOVA revealed a statistical significance (F ¼ 4.836,
p < 0.01, effect size 0.06) in comparison of score and education
model. Post-hoc testing using a Tukey (HSD) revealed that the
statistical significance (p < 0.006) was between the two groups at
the highest and the lowest points of score, namely the ‘elective’
model (which provided theory prior to 40 h of guided experience)
and ‘no formal operating theatre education’ (which provided non-
guided or no practical experience).
Pattern mix
A KruskaleWallis rank test was performed with post hoc testing
using a ManneWhitney Mu test to compare score and pattern mix.
This revealed the only two groups that were statistically signifi-
cantly different from each other (p < 0.001) were ‘theory & guided
practice’ and ‘nothing’.
The three highest mean scores were achieved by students who
were involved in guided practical experience, namely ‘theory,
guided practice and extra experience’, ‘theory and guided practice’
and ‘guided practice’. The four lower scores were achieved by
participants from non-guided practice groups ‘theory and non-
guided practice’, ‘non-guided practice’, ‘theory’ and ‘nothing’.
Time in theatre
Pearson productemoment correlation coefficient was
computed to assess the relationship between the hours spent in
theatre and participant score. This showed a positive correlation
between the two variables (r ¼ 0.183; n ¼ 332; p < 0.001) revealing
the relationship between test score and time (in hours) spent in the
operating theatre. These results were intriguing, and so further
analyses were required to explore this relationship in greater depth.
A regression analysis showed a positive gradient (p < 0.001),
indicating that there was an increased test score as a consequence
of increased time. The overall findings from the correlation be-
tween time in the theatre and participant score showed a statisti-
cally significant relationship, revealing that time is advantageous to
score. Subsequent analysis indicated that time was advantageous
up to about 40e60 h and then seemed to plateau, further indicating
 P. Foran / Nurse Education in Practice 16 (2016) 217e224
that there may be diminishing return on effort after about 60 h in
this undergraduate nursing cohort.
Follow-up study
Participants who were tested as undergraduate nurses, and
other nurses who were at the same level, were tested following
their first year with supported learning. A t-test analysis comparing
score and guided and non-guided practice revealed a p
value < 0.001. From these findings the conclusion is drawn that
there is a statistically significant difference in the knowledge levels
between the two groups (t ¼ 5.958; p < 0.001), namely guided and
non-guided practical experience).
On this basis it is concluded that graduate nurses following their
first year of practice who have been exposed to guided operating
theatre experience as an undergraduate or graduate nurse have
achieved a higher score on the questionnaire on surgical ward
nursing.
In line with comparisons made on the undergraduate cohort,
further pass/fail and guided and non-guided practice comparisons
were made using a t-test analysis. Results revealed a statistical
significance (t ¼ 6.461 p < 0.001). The pass mark was ten out of
twenty.
These results reveal that nurses who had received guided
learning as undergraduates had consolidated their learning as
graduate nurses, thus revealing a higher pass rate (76e100 per
cent).
Discussion
Addressing research question 1
The first research question asked if undergraduate nurses need
to be involved in guided operating suite practical experience in
order to achieve skills and knowledge that support a high standard
of nursing care in the pre- and post-operative surgical wards.
Participants from this research achieved a higher score and pass
rate in knowledge testing following guided as opposed to non-
guided or no operating theatre experience. Areas of surgical
knowledge that were testing included; pre-operative patient edu-
cation, pre- and post-operative nursing care, infection control
(asepsis) and post-operative pain management.
Nurses who did not have guided operating theatre experience
revealed that surgical ward nursing knowledge was deficient in 44
per cent of nurses at the time of graduation and in 47 per cent of
nurses at completion of their Graduate Nurse Program year.
It has also revealed opposing principles when we note that
guided operating theatre clinical experience has been gradually
phased out of most nursing schools' curricula worldwide (Mott,
2012).
International research has informed us that surgical adverse
events were often preventable and deterioration of patients had
occurred without appropriate recognition or treatment (Zegers
et al., 2011; Lomas and West, 2009). In response to these and
similar findings, education has been suggested to ensure the
healthcare workforce is suitably skilled in knowledge of deterio-
ration and subsequent patient care (Australian Commission for
Safety and Quality in Healthcare (2010)).
Sigsby and Yarandi (2004) showed that students who had
guided experience in the operating theatre learnt more than those
who had experience in the medical and surgical wards. Findings
from this research corroborate Sigsby and Yarandi's findings sup-
porting the merits of guided operating theatre experience in
providing superior surgical ward knowledge than what was ach-
ieved from ward experience alone.
223
When operating theatre nursing was removed from the core
curricula, it was replaced with the follow-through style of learning.
In this style of practical, theatre management cannot foresee
attendance by the students, so the educational infrastructure
afforded to the students with guided theatre experience is not
provided. In this scenario, staffing constraints and busyness of the
theatre play a major role in the ability of the students to access
quality supervision and education.
Non-guided participants achieved statistically significant lower
test scores than those from the guided group, supporting comment
by Clark et al. (2012) who stated that ‘there is overwhelming evi-
dence that, for everyone but experts, partial guidance during in-
struction is less effective than full guidance’.
Findings also revealed that 18.3 per cent of undergraduate
nurses did not experience any operating theatre experience in their
entire undergraduate education and a further 9.7 per cent had 5 h
or less. This tells us that 28 per cent of undergraduate nurses who
participated in this national Australian research spent less than half
a day in the operating theatre during their undergraduate degree
preparation. This research have informed us that this is not suffi-
cient to support safe knowledgeable pre- and post-operative sur-
gical nursing care and that the follow-through visits, in their
current format, do not support learning.
Addressing research question 2
The second research question asked about the different models
of operating theatre education offered to Australian undergraduate
nurses and which of these models yielded the best educational
outcomes?
Whilst statistical analyses were performed on the different
models of education, the overwhelming variable in knowledge
acquisition appeared in the comparisons of pattern mix as opposed
to comparisons of models. This was the availability of guided
operating suite practical experience, namely, observing surgical
procedures with guidance from an experienced operating theatre
nurse.
Recommendations
In order to provide a well-rounded, complete understanding of
surgical nursing care it is recommended that guided operating
theatre experience be included in the undergraduate nursing core
curricula (for all students) as part of their preparation for surgical
ward nursing.
Rather than trying to find additional time from within an
already crowded curricula, a portion of time and resources already
allocated to surgical nursing could be effectively reallocated to
encompass guided operating theatre experience. This would be
prudent as the operating theatre has been shown to provide the
desired knowledge and skills required for surgical ward nursing.
This appears to be a ‘winewin’ situation. Universities are having
difficulty in securing acute medical and surgical clinical place-
ments, so the reintroduction of operating theatre placements may
ease this problem. The reintroduction of undergraduate operating
theatre nursing into the core undergraduate nursing curricula
would improve recruitment to perioperative nursing. There is no
doubt that decreased exposure to the operating theatre has been
the major contributing factor in new nurses not entering the field
(Happell, 2000, 2002) and subsequent increase of new staff to the
operating theatre should decrease the pressure on existing staff and
assist in retention of experienced operating theatre nurses. Un-
dergraduate nursing knowledge would increase to provide a higher
quality of surgical nursing care.
224 P. Foran / Nurse Education in Practice 16 (2016) 217e224
The vital caveat to these recommendations would be that re-
sources are provided to initiate guided (as opposed to non-guided)
practical experience.
Conclusion
The genesis of this project followed the possibly preventable
death of a 37-year-old mother of three following routine thyroid
surgery. Findings from this research revealed that, despite this
being a rare complication with a well-documented treatment, only
29 per cent of undergraduates and 45 per cent of graduate nurses at
the end of their education were aware of the correct response in
this situation. This was knowledge I gained as a student nurse via
guided operating theatre experience.
The operating suite should be viewed as an area of rich learning.
As guided operating theatre experience has been shown to deliver
the best educational outcomes it is a recommendation of this
research that all undergraduate nurses should have guided expe-
riential learning in the operating suite as part of their surgical
nursing preparation.
Ethic approval statement
Ethics approval for this doctoral research was sought and
granted by the Faculty of Arts and Education at Deakin University,
Australia. The project was entitled ‘The value of guided operating
theatre experience for surgical ward nurses’. Project number was
HEAG08/27 and was approved on 27th August 2008.
Role of funding source statement
Following the successful completion of my doctoral degree, I
was awarded in 2013 a writing scholarship by Deakin University
Faculty of Arts & Education. This scholarship enabled me to write
this paper.
Conflict of interest statement
There is no known conflict of interest associated with this
research.
Acknowledgements
Deakin University, Faculty of Arts and Education for providing
me with a writing scholarship that enabled the publication of this
paper. To my supervisors Associate Professor Peter Smith and
Associate Professor Damian Blake for their expert comment and
advise on the formation of my doctoral thesis and proof reading of
this paper.
Thank-you to the participants for giving up their time to be
involved in this research.
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