Effect of simulating training of the fundamentals of laparoscopic surgery on the attitude of operating room nurses students: an intervention study
Artikel-Kategorie: Original article
Online veröffentlicht: 16. Sept. 2024
Seitenbereich: 295 - 302
Eingereicht: 01. Jan. 2024
Akzeptiert: 25. März 2024
DOI: https://doi.org/10.2478/fon-2024-0032
Schlüsselwörter
© 2024 Reza Mohebbi et al., published by Sciendo
This work is licensed under the Creative Commons Attribution 4.0 International License.
Clinical education is an essential part of the operating room course and is considered as the heart of professional training.1 Clinical education allows students to gain useful experiences through learning clinical interventions that play a key role in their professional preparation for patient care.2 Despite the importance of clinical education, it still faces many challenges. A relevant study, which was conducted in Iran, showed that 88% of nursing graduates are dissatisfied with the quality of clinical education.3
The operating room is one of the high-risk and high-stress environments for patients and one where clinical education is very important. Some of the problems occurring in patients postoperatively are due to the errors committed by the operating room staff. Although the number of these errors is not high, they may lead to patient death. Therefore, studies show the lack of clinical skills of operating room graduates.4,5
The operating room is a new field of study and is dependent mainly on the practical and clinical skills of operating room graduates. A previous study has shown that despite having a strong theoretical foundation, operating room students do not have the skills and abilities needed in various surgeries.6 Operating room students, as the future professional staff, may commit medical errors, and practical training courses give students the opportunity to implement their theoretical knowledge in a real environment.1 Considering the increase in the number of minimally invasive surgeries (MISs) and the rapid development of surgical technology in this field, the use of new curricula to improve the attitude of operating room personnel is essential.7 Recently, simulation training has become a common method of teaching surgical skills. Although simulation training is widely used for residents, it is not yet common for operating room students, who will play the role of scrubs and assistant surgeons in the future. Simulation training aims to make the learning conditions closer to the real environment.8
Laparoscopy is one of the most important MISs in which surgical interventions are performed through small incisions in the abdominal wall using long instruments. Lower pain and bleeding and shorter length of stay are among the advantages of laparoscopic surgery compared with open surgeries.9 In most operating rooms, surgical technologists, as assistant surgeons in the laparoscopic surgery team, are responsible for camera navigation and peg transfer, which means that the surgeon’s eyes are in the hands of another person. For this reason, the skills of the surgeon’s assistant are highly important in MISs.10 Thus, the attitude of operating room students toward these skills is essential.9 Considering that surgical errors can have an irreparable impact on patients, it is necessary to improve students’ attitudes toward controlling and reducing these errors.11
Measuring and improving students’ attitude is extremely important to treatment goals, especially in hospital wards.12 People’s performance and skills are influenced by their attitudes. Gordon Allport believes that attitude is a state of mind that directly affects a person’s reaction to all situations.13 A positive attitude is the main factor required for improving the performance and skills of surgeon’s assistants, so that they can develop the appropriate skills needed during surgery.14,15
The laparoscopic surgery team needs to practice in the simulation environment before working in the real operating room.16 Accordingly, operating room students as future nurses play an important role in providing high-quality care to surgical candidate patients, and the performance and skills of operating room nurses are influenced by the attitude they possess. Also, to our knowledge, there was no similar study in Iran. Therefore, the present study was conducted to determine the effect of simulating the training of the fundamentals of laparoscopic surgery (FLS) on the attitude of operating room students.
This single-group intervention study was conducted on 30 operating room students at Iran University of Medical Sciences, Tehran in 2019. The census sampling method was used. Inclusion criteria were the willingness to participate in the study, being a student in the last semester of the BSc period, and completing a training theoretical course in gastrointestinal and endocrine surgical technology. Exclusion criteria were absent during the educational intervention and transferring from another university. The research was carried out in 5 stages (Figure 1).
Five stages of the research undertaken.
At the beginning of the study, aspects such as the purpose of the study, how to complete the questionnaire, and how to run the educational simulator were explained to the participants. Prior to the educational intervention, for determining the attitude of the students, the attitude-measurement questionnaire was completed by the students. The booklet containing the principles of laparoscopic surgery, which was designed based on the FLS curriculum and also following the operating room technology curriculum in Iran under the supervision of the operating room professors, was delivered to the students. This curriculum focuses on laparoscopic surgical techniques and includes 2 components (theoretical knowledge and practical skills). The general goal of this curriculum is to provide standard training in the FLS to surgical assistants.
The theoretical part of the FLS curriculum consists of 10 sections: (1) indications for laparoscopic surgery, (2) surgical position, (3) tools and equipment, (4) anesthesia care, (5) access to viscera and care of ports, (6) hemostasis, suture, and stapler, (7) gas pressure and biopsy, (8) exit from abdomen, (9) perforation of intestines and large vessels and embolism, and (10) bleeding and hypothermia. The practical skills section of the FLS curriculum includes five main laparoscopic surgery skills: (1) peg transfer skill, (2) cutting a circular pattern, (3) creating a ligation loop, (4) intracorporeal suturing, and (5) extracorporeal suturing.17–20 In newer studies, the “camera navigation” item was also added to this curriculum.21,22 Considering the role of the operating room student who will work as a surgeon’s assistant in the future, 3 tasks including peg transfer, cutting a circular pattern, and camera navigation were investigated in this study.9,23 Figure 2 shows the students’ performance.
Training and assessing the triple laparoscopic surgery skills in the MISs research center at Rasoul Akram Hospital. (A) camera navigation skill; (B) peg transfer skill; and (C) cutting a circular pattern skill. MISs, minimally invasive surgeries.
Students studied this booklet for 30 days. To track the study status of the students, a group on the Telegram social network was used, and their questions were answered. In the next stage, the students were divided into 3 groups of 10 people each based on their attending the minimally invasive surgery-simulation training center. For each group, one day of simulated center time was allocated for the teaching of and practicing the practical skills. After completing this stage, the same attitude-measurement questionnaire was completed again by the students.
The Intrinsic motivation inventory (IMI) was used to measure students’ attitude toward laparoscopic surgery, and included 22 questions in 4 dimensions, including (1) interest, (2) perceived competence, (3) perceived choice, and (4) pressure/tension. This questionnaire was scored based on a 7-point Likert scale ranging from 1 (completely disagree) to 7 (completely agree). Also, questions 2, 9, 11, 14, 19, and 21 were scored in reverse. The possible score range was from 22 to 154. This questionnaire was developed by Ryan et al.24 and was used by Nielson et al.25 to investigate the attitude of laparoscopic surgery students. The validity and reliability of this questionnaire were calculated to be 0.86 and confirmed by Hamldar et al.26 in Iran.
Data analysis was done using descriptive and inferential analyses. The Shapiro–Wilk test was used to check the normality of the variable distribution before and after the educational intervention.
Considering that the student’s attitude scores had a normal distribution, the paired
The present research was approved by the Ethics Committee of Iran University of Medical Sciences with the code of ethics (IR.IUMS.REC 1396.9511101009) and an access link (https://b2n.ir/k27781). Before the study, the participants were informed about the objectives of the study and they signed the informed consent form. Participants’ information was kept confidential, and their names were replaced with codes. The participants could withdraw from the study at any stage. A consent form was obtained from the participants of the study to publish the image.
The mean ± SD of students’ age was 22.93 ± 2.14 years. The majority of the sample participants were female (
The mean, standard deviation, and significant difference of students’ attitude scores in 4 dimensions before and after the educational intervention.
| Dimensions | Mean ± SD Before intervention | Mean ± SD After intervention | |
|---|---|---|---|
| Interest | 291.67 ± 67.69 | 492.86 ± 46.35 | <0.001 |
| Perceived competence | 280 ± 45.60 | 288.46 ± 47.04 | <0.001 |
| Perceived choice | 352.59 ± 76.69 | 498.52 ± 66.08 | <0.001 |
| Pressure/tension | 378.57 ± 64.61 | 330.71 ± 61.21 | <0.001 |
| Total | 291.67 ± 67.96 | 492.86 ± 46.35 | <0.001 |
The results of our study also showed a significant and positive correlation between gender and the interest dimensions with students’ attitudes (
Determining the relationship among gender, age, and the dimensions of students’ attitudes.
| Dimensions | Mean | ||||
|---|---|---|---|---|---|
| Male | Female | ||||
| Interest | 490.00 | 498.00 | 0.005** | 0.921*** | 0.020 |
| Perceived competence | 11.80 | 15.08 | 0.311* | 0.411**** | 0.165 |
| Perceived choice | 17.80 | 12.80 | 0.131* | 0.438**** | 0.153 |
| Pressure/tension | 311.00 | 340.00 | 0.511** | 0.041*** | -0.389 |
Women had more “interest” scores. However, no significant relationship was observed in the other dimensions. Also, a significant and negative correlation was found between age and pressure/tension (
The present study aimed to determine the effect of simulating training in the FLS on the attitude of the operating room students. The results showed a significant difference between the attitudes of the operating room students toward the FLS before and after the educational intervention in the 4 dimensions, namely, interest, perceived competence, perceived choice, and tension. These results are consistent with the study conducted by Lee and Kim.27
In the study of Hafford et al.28 the attitudes of surgeons and operating room personnel regarding the effectiveness of FLS principles improved after a simulated educational intervention. Also, in the study of Lee and Kim,27 the attitude of operating room nurses improved after the implementation of a simulated intervention about patient safety during surgery.
Other studies also confirm the results of the present study. For example, the result of Burden et al.’s29 study emphasizes that the simulated training of the principles of laparoscopic surgery will improve the attitude of gynecologists.
The use of simulation in nursing can lead to the expansion of knowledge, skills, performance, critical thinking, and self-confidence in nurses. Also, the results of another study showed that using the training manual can also improve the attitude of nurses regarding preparedness in crises.30
The current study showed a significant increase in the interest of students to perform the FLS after the educational intervention. This increased interest among students can be due to the greater knowledge now possessed, correct understanding of the laparoscopic environment, the presence of technology, and the attractiveness of the workplace found for this type of surgery. Nilsson et al.25 in 2016 conducted a study with the aim of comprehending the effect of laparoscopic surgery simulation training on students’ attitudes and skills. Unlike the present study, the results of Nielson’s study showed that the level of interest in the control group was higher than that in the simulation group. Considering that the control group did not receive any training on the skill of camera navigation in laparoscopic surgery, it is possible that in Nilsson’s study, lack of familiarity with the environment of laparoscopic surgery caused this result in the control group.
The perceived competence of the students was also investigated in the present study, and the results show a significant improvement in this dimension after the educational intervention. The low preintervention perceived competence may be due to lack of knowledge and understanding of laparoscopic procedures, techniques, and skills, but the students felt higher perceived competence after the intervention. LaPorta et al.31 investigated the effect of simulating surgical skills on the self-confidence and clinical knowledge of students. Consistent with the current study, they concluded that this training course may increase the self-confidence and clinical knowledge of surgical students. Geoffrion et al.32 further showed that theoretical knowledge training alone does not change the self-confidence of surgical students, but that simulation-based training together with theoretical knowledge training helps to improve people’s self-confidence. In addition, the study of Amiri and Khademian mentioned the use of simulated training as a basic principle in fostering the clinical competence of nurses. Operating room students, as a group of future personnel based in the surgical team, have an abstract thinking of the conditions of facing problems in clinical environments; thus, the use of educational methods based on simulation to improve clinical decision-making in this group is also recommended.33
Also, in the present study, a third dimension showed the rate of perceived choice of operating room students and their preference in choosing to study laparoscopic surgeries compared with other surgeries. The results obtained show a significant difference in the perceived choice mean scores after the educational intervention, which was inconsistent with the study by Nilsson et al.25 This discrepancy shows that students preferred laparoscopic surgeries compared to other surgeries with the increase in their knowledge and awareness of the laparoscopic surgery environment and workplace.
The fourth dimension of the IMI investigated the tension rate of students during laparoscopic surgery. The mean score of tension/pressure was significantly reduced after the intervention. The high preintervention tension/pressure rate shows that students are anxious when facing laparoscopic surgery techniques for the first time, which is probably due to their low level of knowledge and skills. However, with an increase in their skills and self-confidence, they felt more comfortable and had lower tension and pressure after the intervention. Consistent with the present research, Pupkiewicz et al.34 showed that novice students experienced fear and anxiety when performing surgical techniques. The participants also stated that they needed more comprehensive curricula so that they can acquire sufficient skills and knowledge to participate in surgical procedures. In line with the results of the present study, the study of Ebrahimian et al.35 showed that simulation can reduce the anxiety and tension of operating room students during the internship period.
The present study also revealed a significant relationship between interest and gender. The higher level of interest seen among female students can be because the majority of participants were female, and these results are consistent with the study by Glaser et al.36 In the present study, there was a significant and negative correlation between age and pressure/tension, so that with increasing age, the amount of pressure/tension may decrease. In line with this finding, in the study of Mahdaviseresht et al.37 it was pointed out that increasing age reduces the work tension of nursing students, and this may be due to greater familiarity of the stressful environment of clinical work and increased experience.
The results of the present study show that simulating training of FLS has a positive effect on students’ attitudes. Also, despite the short period of training and performing it on simulated laparoscopic mollage, the results show that the curriculum was highly effective in all dimensions. With the addition of this subject to the operating room curriculum, it can be expected that students have a positive attitude toward the FLS and prepare themselves for effective attendance in the operating room.