Education in the Health Professions

ORIGINAL RESEARCH
Year
: 2020  |  Volume : 3  |  Issue : 3  |  Page : 110--115

The effectiveness of an operating room etiquette video on medical student comfort in the gynecologic operating room


Mallory A Stuparich1, Alexandra I Melnyk2, Heather L Hohmann2, Jessica K Lee3, Marnie H Bertolet4, Nicole M Donnellan2,  
1 Department of Obstetrics and Gynecology, University of California Riverside School of Medicine, Riverside, CA, USA
2 Department of Obstetrics, Gynecology, and Reproductive Sciences, MageeWomens Hospital of UPMC, University of Pittsburgh School of Medicine, Baltimore, MD, USA
3 Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
4 Department of Epidemiology, Biostatistics, Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA, USA

Correspondence Address:
Dr. Mallory A Stuparich
Department of Obstetrics and Gynecology, University of California Riverside School of Medicine, 14350 Meridian Parkway, Riverside, CA 92518
USA

Abstract

Background: Medical students spend a large portion of their obstetrics and gynecology (OB/GYN) rotation in the operating room (OR). We identified a deficit in appropriate OR orientation and created a 10-min video reviewing OR etiquette and fundamental skills. Our primary aim was to investigate the effect of this video on medical students' comfort and self-assessed performance in the gynecologic OR. Our secondary aim was to examine if OR personnel rated students' performance higher 8 months after video introduction. Materials and Methods: A prospective, cohort study of 71 3rd- and 4th-year medical students participating in the core OB/GYN clerkship at the University of Pittsburgh Medical Center (UPMC). All medical student participants watched the video once during their clerkship orientation and had continuous online access. Participants completed a pre- and posttest survey assessing their comfort with various OR tasks. After each OR day, participants completed a brief self-assessment of their OR performance. OR staff were surveyed on medical student performance before and after video implementation. Data were analyzed using descriptive statistics, the signed-rank test, and Fisher's exact test via SAS 9.4 (SAS Institute, Inc., Cary, NC, USA). Results: Most students reported improvement on the daily self-assessment. Students without prior surgical experience demonstrated greater improvement in comfort with most OR tasks. OR staff perception of medical students changed favorably after video implementation in several domains. Conclusions: A brief video detailing OR etiquette and fundamental skills is an easily implemented resource to clarify OR tasks that often produce unnecessary anxiety for students. Improved OR staff perception of medical student performance may help streamline OR functioning.



How to cite this article:
Stuparich MA, Melnyk AI, Hohmann HL, Lee JK, Bertolet MH, Donnellan NM. The effectiveness of an operating room etiquette video on medical student comfort in the gynecologic operating room.Educ Health Prof 2020;3:110-115


How to cite this URL:
Stuparich MA, Melnyk AI, Hohmann HL, Lee JK, Bertolet MH, Donnellan NM. The effectiveness of an operating room etiquette video on medical student comfort in the gynecologic operating room. Educ Health Prof [serial online] 2020 [cited 2021 Jun 13 ];3:110-115
Available from: https://www.ehpjournal.com/text.asp?2020/3/3/110/300076


Full Text



 Introduction



The operating room (OR) can be a challenging and high-stress learning environment for medical students who are often appropriately apprehensive regarding how to behave, identifying anxiety and fear as learning barriers.[1],[2],[3] In addition, the educational efforts in the OR may be mostly aimed at teaching the technical steps of a procedure to surgical residents and fellows rather than teaching core clerkship objectives to a medical student.[4]

Both 4th-year medical students and obstetrics and gynecology (OB/GYN) faculty have defined understanding surgical culture and OR functioning (i.e., clarification of students' role, comfort with team, and physical positioning to be helpful but not interfering) to be key learning objectives, noting that a better understanding of these objectives decreased student anxiety and improved the learning experience.[5] Computer-based instructional modules and videos that introduce OR culture have been associated with improved student self-confidence and satisfaction.[1] A needs assessment at our institution identified that OR staff often have concerns about how medical students function in the OR. However, to our knowledge, no study has had OR personnel who evaluate medical student performance after the introduction of a single video intervention providing instruction on OR etiquette and tasks into an established OR curriculum.

Before this study, students in our core OB/GYN clerkship underwent a one-time OR orientation on the 1st day of the rotation, including an introduction to surgical scrubbing, gowning, and gloving by a nurse educator. Beyond this orientation, the students only received informal, unstructured teaching in the OR by the residents, fellows, or faculty. Furthermore, not all students participate immediately in OR activities in their clerkship. Those that experience a delay (e.g., students starting in the ambulatory OB/GYN clinic) may struggle to recall and implement the lessons taught during their orientation. Due to the heterogeneity in OR instruction quality and variable timing of medical student OR participation, we created and added a 10-min video reviewing OR etiquette and fundamental skills such as scrubbing, gowning and gloving, patient positioning, and surgical skin preparation to the existing clerkship curriculum.[6]

Our primary aim was to investigate the effectiveness of this video on medical students' comfort and self-assessed performance in the gynecologic OR. Our secondary aim was to examine if OR personnel rated students' performance higher 8 months after the introduction of the video.

 Materials and Methods



We conducted a prospective, cohort study of 3rd- and 4th-year medical students participating in the 4-week core OB/GYN clerkship at the Magee-Womens Hospital of UPMC from January 2017 to July 2017. This cohort included students from the end of the 2016–2017 academic year (January 2017–April 2017, rotation blocks 10–12, respectively) and students from the beginning of a new academic year (May 2017–July 2017, rotation blocks 1–3, respectively) and spanned 64-week blocks. The study was approved by the Institutional Review Board at the University of Pittsburgh (PRO16050003).

Informed consent was obtained from all participants during their orientation on the first clerkship day. All students received the standard OR instruction during orientation, which included 45 min of didactic instruction on scrubbing, gowning, and gloving performed by a nurse educator. Regardless of study participation, all students also viewed the brief video, which detailed OR etiquette, scrubbing, gowning and gloving, patient positioning, and surgical skin preparation (Video link: https://youtu.be/vCtUMvviRHM). Students had continuous online access to this video and were given an identification number which allowed study investigators to track video access frequency.

All study participants completed a pretest survey (before video intervention) during clerkship orientation and a posttest survey (after video intervention) 4 weeks later upon conclusion of the clerkship. Participants rated their own comfort on a 5-point Likert scale (1 – least comfortable and 5 – most comfortable) of performing the following OR tasks: using personal protective equipment, sterilely opening gowns and gloves, completing a full surgical scrub, donning a gown and gloves with assistance, and donning a gown and gloves without assistance.

During the OB/GYN clerkship, all students completed a 7-day OR subrotation on either the benign gynecology or gynecologic oncology service. Study participants completed self-assessments after each OR day, estimating the number of self-perceived errors and clarifying questions they asked regarding how to gown and glove properly. Participants were then asked to rate if they felt fully comfortable to gown and glove without assistance as well as how many times they viewed the 10-min OR etiquette video in the preceding 24 h.

OR personnel, including nurses and scrub technicians, were surveyed regarding their perception of medical student performance in the OR before and after video implementation. They were given a pretest survey (before video introduction) and a posttest survey (8 months after video introduction) containing statements on medical student performance juxtaposed with statements on surgical fellow performance to serve as an internal control. OR staff were asked to rate their agreement with these statements on a 5-point Likert scale (1 – totally disagree and 5 – totally agree). Staff members were never presented with the plan to implement the video and were unaware that any intervention had taken place between their pre- and posttest surveys.

Statistical methods

The cohort was described using categorical baseline variables summarized using percentages and counts.

Analysis of students' pre- and posttest survey responses included only those participants who answered the questions at both time points. The pretest survey responses from each participant were subtracted from their respective posttest survey responses with a positive value indicating a larger postintervention response. These differences are reported by question and by rotation block number. The signed-rank test was used to determine if there was a significant improvement on each question.

Students were compared based on their prior surgical experience. Study participants received 1 point for each of the following: having completed a prior general surgery rotation, having completed any other surgical rotation, and having spent 15 or more hours shadowing in an OR before the clerkship. Using these points, they were placed into the following groups: 0 points – no prior experience, 1 point – minimal prior experience, 2 points – moderate prior experience, and 3 points – high prior experience. For each rotation block, the number of participants whose score decreased, remained the same, and increased was tabulated. These tabulations were compared across blocks using a Fisher's exact test to determine if the effect of the intervention varied by block.

Analysis of student self-assessment data included only data that were recorded during the OR subrotation for each participant. Participants' responses were averaged by OR day.

Analysis of OR staff pretest and posttest survey responses included only those staff participants who answered the questions at both time periods. The pretest survey results were subtracted from the posttest survey results and averaged across OR staff participants to determine the average change. Positive values indicated a better perceived performance of either the medical student or a fellow at study completion. The signed-rank test was used to determine if the result differed from zero.

All analyses were performed using SAS 9.4 (SAS Institute, Inc., Cary, NC, USA).

 Results



From January 30, 2017, to July 30, 2017, 71 out of 75 (94.7%) medical students participating in the core OB/GYN clerkship at Magee-Womens Hospital of UPMC were enrolled in the study. One student withdrew and seven students were lost to follow-up, resulting in an analytic sample of 63 participants [Table 1]. Most students were in their 3rd year (90%, n = 57) with only 5 students (8%) in their 4th year. With regard to clerkship timing, 54% of the participants completed their OB/GYN clerkship in the first 3 months of the new academic school year (n = 34; May 2017–July 2017; rotation blocks 1–3, respectively) while 46% completed their OB/GYN clerkship in the final 3 months of the previous academic year (n = 29; January 2017–April 2017; rotation blocks 10–12, respectively). Over half of the students had already completed their general surgery rotation (56%, n = 35), and 19% (n = 12) of students had completed another surgical rotation before study enrollment. Most students (77%, n = 48) had already shadowed a surgeon before their OB/GYN clerkship.{Table 1}

On average, participants had a >1-point improvement in self-reported performance of OR tasks [range of averages of improvement 1.1–1.3; [Table 2]. Self-reported improvement in rotation blocks 1–3 was significantly higher than the improvement in rotation blocks 10–12 in the use of personal protective equipment (1.8 vs. 0.8, P = 0.030), sterilely opening gown and gloves (1.7 vs. 0.6 P = 0.006), completing a full surgical scrub (1.9 vs. 0.6, P = 0.023), and donning gown and gloves with assistance (1.9 vs. 0.6, P = 0.004). Responses to each question were compared within rotation blocks 1–3 and again within rotation blocks 10–12 and demonstrated no significant difference (data not shown).{Table 2}

Students' self-reported improvements were also analyzed based on their prior surgical experience with 33% (n = 21) of students reporting no prior experience, 33% (n = 21) of students reporting minimal prior experience, 19% (n = 12) of students reporting moderate prior experience, and 14% (n = 9) of students reporting high prior experience. The less prior surgical experience participants had, the more likely they were to report an increase in comfort using personal protective equipment, gowning and gloving, completing a full surgical scrub, and donning a gown and gloves with assistance [Table 3].{Table 3}

When asked for feedback on the video, 78% of the students reported that they would recommend the video to peers, which was independent of block or prior experience (data not shown).

Students also performed daily self-assessments of gowning and gloving tasks during their benign gynecology or gynecologic oncology OR subrotation. Thirty-one students (49%) submitted all or a portion of their daily self-assessments. The average response across participants was calculated for each question on each OR day and is summarized in [Figure 1]. The number of clarifying questions asked about properly gowning and gloving decreased over the subrotation. On day 1, the mean number of questions asked was 1.13, and by day 7, the mean was 0.27. Means in perceived errors in gowning and gloving decreased over the 7-day period, from 0.68 on day 1 to 0.35 by day 7. The average number of times the video was watched was highest on day 1 (12 views from 31 students = 0.39 views/student on average) with minimal to no viewing on the following 6 days. The percentage of students that had full confidence in independent gowning/gloving increased from 50% on day 1%–76% on day 3, with a decrease in day 5%–43%. Ultimately, a greater percentage of students felt more confident on day 7 (81%) compared to day 1 (60%).{Figure 1}

[Table 4] demonstrates the results from the OR staff pretest and posttest surveys. A total of 40 staff members completed the pretest survey, and 33 of these 40 (82.5%) completed the posttest survey. Overall, OR staff evaluation (using a 5-point Likert scale) of medical students changed favorably in their perceptions of their efficiency (+0.48, P = 0.003), ability to gown and glove (+0.61, P = 0.0028), and interference with staff's ability to care for patients (−0.47, P = 0.028). There was no significant change in staff perceptions of surgical fellow performance during the similar time period (−0.09–+0.19, P = 0.45–1.0).{Table 4}

 Discussion



Principal findings

Implementation of a 10-min OR etiquette and fundamental skills video in a core OB/GYN clerkship was associated with an overall student self-assessed improvement in the comfort of using personal protective equipment, sterilely opening a gown and gloves, performing a full surgical scrub, and donning a gown and gloves with assistance. OR staff perception of medical students changed favorably in the domains of efficiency, ability to gown and glove, and interference with staff's ability to care for patients.

Clinical implications

Given the higher increase in self-assessed comfort in performing OR tasks in the beginning of the academic year and for students with no previous surgical experience, the content of our video is likely more applicable to novice learners. However, regardless of prior experience, 78% of the students would recommend this video to their peers, and many recommended that it be used before other surgical clerkships, demonstrating its general utility for OR-naïve students. Even for more advanced learners, this tool may provide students a safe resource to clarify steps of procedures that often produce unnecessary anxiety in the OR environment. Moreover, comfort and earlier mastery of these preliminary tasks may relieve student anxiety enough that they can focus more intently on learning related to the actual surgical procedure.

OR staff who were blinded to the video intervention rated medical student efficiency and preparedness more favorably following video introduction despite being surveyed in the new academic year when it may be expected that medical students would be less experienced and efficient. Thus, medical student self-improvement in comfort performing various OR tasks following video introduction may parallel actual performance change in the OR as perceived by OR staff.

Strengths

No study to our knowledge has analyzed the change in OR staff perception of medical student functioning in the surgical suite, which is a key element in streamlined OR functioning. We found an associated improvement in both student and OR staff perceptions of medical student comfort, efficiency, and performance of various tasks in the gynecologic OR after video introduction. Thus, assessment of medical student functioning in the OR by OR staff may support the actual effectiveness of the video intervention in impacting behavioral change rather than simply reporting on the medical students' perceptions of the novel video intervention.

To our knowledge, this is the only study involving the addition of a simple, brief video intervention detailing OR etiquette and fundamental skills to an existing OR orientation curriculum. While our study design mirrors the work of Hampton et al., their intervention requires construction and implementation of an entirely new OR curriculum, which included orientation of both students and faculty to learning objectives, construction of computer-based modules for student education, creation and distribution of student experience and skill cards, and collection and review of a student reflective assignment.[1] In contrast, our intervention is simple, inexpensive, and requires minimal resources to implement.

Limitations

The greatest limitation to our study is that we were unable to randomize participants to receiving or not receiving the video intervention. While planning the study methodology in close conjunction with medical education specialists at our institution, we concluded that it would be unethical to randomize medical students to groups that could withhold a potentially helpful intervention that may ultimately impact their education and clerkship grades. In addition, we recognize that significant changes in participant self-assessed improvement, comfort, and confidence with performing OR tasks may have occurred from repeatedly participating in the daily activities of the OR itself. To this point, it is also difficult to compare 3rd- and 4th-year medical students together given that 4th-year medical students have more clinical experience. Interestingly, the 4th-year medical students were only enrolled in the clerkship in rotation blocks 1–3 at the beginning of the academic year. Despite their limited presence, which would likely obscure any difference in self-assessed improvement of performing various OR tasks, students still noted an overall positive change. By incorporating OR staff perception into the study design, we hoped to demonstrate that the change in self-assessed student comfort led to an observed change in behavior in the OR from individuals outside of the clerkship structure. We also recognize that prior OR experience can significantly change a student's comfort in the OR environment, which we attempted to control for by assigning points based on prior OR experience. However, there may have been additional OR experiences that students may have that we were unable to account for in our analysis. Additional limitations include a small sample size and that the study was conducted at a single institution.

Research implications

Future investigations may focus on analyzing these same outcomes within a single academic year with no curriculum changes and then conducting the same analysis after video implementation, which would help account for temporal biases. Because our video content is useful to OR-naïve students, implementing such a video at an earlier point in medical school, such as in the preclerkship orientation, may also result in a more significant impact in procedural learning. Further, partnering with other institutions to support generalizability to undergraduate medical education at large would also strengthen findings to support the benefits of implementing a brief video intervention detailing OR etiquette and fundamental skills.

 Conclusions



A brief video detailing OR etiquette and fundamental skills shown at the beginning of an OB/GYN clerkship is associated with statistically significant improvement in medical student comfort with performing basic OR tasks. Constant access to the video allows students to conveniently review important OR tasks, especially when their surgical days are remote from OR orientation. This video may be useful before any surgical clerkship as a general review of OR etiquette and fundamental skills and can be used at any time during training.

Financial support and sponsorship

The project described was supported by the National Institutes of Health through Grant Number UL1TR001857. This support played a role in the statistical analysis of this work.

Conflicts of interest

There are no conflicts of interest.

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