Keywords

1 Introduction

Norway offers one of the world’s most comprehensive educations in operating room (OR) nursing. The postgraduate program consists of 90 European Credit Transfer and Accumulation System (ECTS) credits and covers three full-time semesters comprised of half theoretical and half clinical studies. All universities will offer an optional extension of the course with a fourth semester, which results in a master’s degree (30 ECTS credits) from 2022. Admittance to the program typically requires a bachelor’s degree in nursing (180 ECTS credits). Theoretical studies offer a variety of pedagogical methods, including lectures, group work, academic writing, seminars, workshops, skills training, and simulation. Norwegian OR nurses have therapeutic, pedagogical, and administrative roles, as well as responsibilities for research and professional development [1]. The OR nurse fulfills the functions of both scrub and circulating roles. Alternating between the two roles, the OR nurses work in teams of two who interact constantly with each other. The OR nurse performs technical tasks, and patient care in complex situations, and must master both technical and non-technical skills to ensure patient safety in interdisciplinary collaboration within the surgical team [2]. To achieve the best standard of care, OR nurses must be proficient in the responsibilities and functions of both OR nursing roles, including teamwork and other non-technical skills. Mastery of technical and non-technical skills go hand in hand [3]. In the highly technological surgical environment, the OR nurse is part of a professional surgical team. In preparing the patient and OR for surgery, the scrub and circulating nurses work in close collaboration with nurse anesthetists. Most adverse events that jeopardize the safety of hospitalized patients occur in the surgical setting, and near-misses and unintended harm caused by human factors are potentially avoidable [4]. OR nurses have long been familiar with the non-technical skills essential to their role, but the knowledge has been tacit. The Norwegian adaptation of the Scrub Practitioners’ List of Intraoperative Non-Technical Skills (SPLINTS-no) system provides OR nurses with a common vocabulary and structure of non-technical skills. Using SPLINTS-no as a supportive training tool improves communication and descriptive skills between OR nurses, increasing awareness of non-technical skills, and encouraging reflection [5]. This chapter will describe the planning, implementation, and evaluation of non-technical skills simulations in an OR nursing program in Norway. The simulations were run as a sequence of two low-fidelity scenarios (in which the OR nursing students prepared the patient and the OR for surgery) and a third high-fidelity scenario of preoperative preparations involving both OR and anesthetic nursing students. SPLINTS-no was used as a tool for reflection and learning for the OR nursing students in debriefing sessions.

2 Choosing Simulation as a Pedagogical Method

In higher education, the choice of learning activities and pedagogical method is determined chiefly by measurement and comparison of educational outcomes. It has been argued that the purpose and quality of education, rather than its effectiveness, should be the primary considerations when designing educational processes. Education can be described with three purposes: qualification, socialization, and subjectification. Qualification refers to knowledge, skills, and understanding acquired as a result of education, while socialization relates to how education allows students to become part of social, cultural, and political orders. Subjectification is described as the opposite of the purpose of socialization—a way of remaining independent from such orders by becoming autonomous and trusting one’s own decisions [6].

In OR nursing education, we suggest that all three of these purposes must be considered when designing learning activities. An OR nurse must acquire a specific set of skills and knowledge and become a functional part of a surgical team through designated learning activities and experience in clinical practice [2]. In addition, OR nurses must be capable of making independent decisions in (sometimes critical) situations to ensure patient safety [7]. Despite this, leadership and decision-making skills are sparsely recognized in OR nursing literature, and further research and development is needed for educational training and pathways for both circulating and scrub nurses [8].

Simulations are increasingly being used as an approach to learning in OR nursing, as they allow students to improve their teamwork and communication skills in a safe environment [9]. Simulating OR scenarios with interdisciplinary student groups improves team behaviors [10] and attitudes [11], enabling the students to develop a better understanding of each other’s roles in achieving a common goal. Interdisciplinary simulation promotes trust within the team [12] and has the potential to break down silos in the OR [11]. The learning process in a simulation activity is reinforced by proceeding directly to feedback and debriefing following the simulation [13]. Feedback literacy is described as the student’s ability to understand, utilize, and benefit from feedback processes [14]. When students are more actively involved in the feedback process, it develops their capacity to judge the quality of both their own work and that of others and to make informed decisions in their own practice [15]. Peer feedback has been shown to be particularly valuable in developing these skills, as it encourages students to more carefully evaluate the actions of others and thus reflect on their own performance [14].

3 SPLINTS and SPLINTS-no

The first classification tools for evaluating non-technical skills in healthcare were developed originally for anesthesiologists [16] and surgeons [17] and were followed by evaluation tools for nurse anesthetists [18] and OR nurses [3, 19,20,21]. The Scrub Practitioners’ List of Intraoperative Non-Technical Skills (SPLINTS) assessment tool was designed specifically for scrub nurses during surgery [20], listing non-technical skills under the categories of situation awareness, communication and teamwork, and task management to provide a common framework and language [21].

Norwegian OR nurses work in pairs and alternate between the scrub and circulating nurse roles, both of which are essential for ensuring patient safety in the OR. Non-technical skills assessment tools should be adjusted to the culture in which they are utilized [22], and customized to fit the target group of professionals [23], but few studies have identified the non-technical skills of circulating nurses [8]. To attempt to remedy this, the SPLINTS-no assessment tool was launched in 2017 [24]. SPLINTS-no describes good and poor professional behavior of both scrub and circulating nurses [25]. To make this tool more comprehensive, further adaptation is required to capture the non-technical skills of both OR nursing roles and functions, and further research into the non-technical skills of the circulating nurse is needed [26].

SPLINTS-no is well accepted by OR nurses as a supportive tool in supervising and increasing awareness of non-technical skills during OR student nurse clinical placements, and frequent training is required to become sufficiently familiar with SPLINTS-no to use the rating system correctly [5]. SPLINTS-no has three categories of non-technical skills, situation awareness, communication and teamwork, and task management, which are further divided into a total of nine elements (Table 1) and was used to provide the OR nursing students with a common framework and language for the simulation exercises.

Table 1 Categories and elements of SPLINTS-no adapted from Mykkeltveit and Bentsen [24]; Sirevåg et al. [5]
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4 Planning the Simulations

Prior to beginning simulation activities, several meetings were held between the nurse anesthetist and OR nursing teachers, during which learning outcomes and goals for the two study programs were discussed. Teamwork and patient safety in the OR were identified as common ground, and it was agreed that non-technical skills would be the focused learning objective for the simulations. It was important for the teachers involved that the learning objectives of the simulation activity were few in number, focused, and clearly stated [13]. The teachers agreed to use the non-technical skills assessment tools SPLINTS-no and Nurse Anesthetists’ Non-Technical Skills (N-ANTS) as frameworks for the simulations and to create a scenario involving two nurse anesthetists, a circulating nurse, and a scrub nurse. Information on learning objectives, groups, time schedule, and meeting points was published on the students’ digital learning platform prior to the simulations.

The OR nursing teachers decided to run two separate professional scenario simulations with the OR nursing students prior to advancing to the third, more complex, interdisciplinary simulation that included the nurse anesthetist students. The collegial team agreed on three scenarios for simulations that could be run using available resources and were engaging to the students, allowing them to achieve the intended learning outcomes of teamwork and non-technical skills in the OR (Fig. 1).

Fig. 1
A chart is divided into 3 parts titled scenarios 1, 2, and 3 which include the gender, age, and medical history of a patient, among others. Each part contains scenarios used for simulations.

The three scenarios used for simulation

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Creating a gradual progression in difficulty level in the simulation training has been shown to enable more effective learning [27]. To optimize the learning benefits of the third simulation (which involved preparing for an advanced emergency surgery case of necrotizing fasciitis), the OR nursing students first underwent two simulations in a basic presurgical OR setting with two simple outpatient cases, which required the use of non-technical skills within the OR nursing team. It has been shown that simulations flow more smoothly when the students have had prior experience of the simulation setting [28].

It is widely recognized that the debriefing process is essential for achieving a deeper understanding of the skills developed during a simulation [29,30,31], and sufficient time must be allowed for this [13, 32, 33]. The expected duration of each of the three scenarios was 30 min. A further 40 min was set aside for debriefing, as the literature suggests this is given at least the same amount of time as was spent on the scenarios [13, 32, 33].

Knowledge of the professional field is essential to provide students with adequate support throughout every stage of the simulation activities [13]. To ensure this, the teachers involved in the simulations were all either OR nurses or nurse anesthetist professionals, as well as experienced teachers, trained facilitators, and simulation technicians. As simulations can often run unpredictably [13], the experience of the teachers involved ensured that any unexpected events were handled in a professional manner and that the simulation laboratory was set up comprehensively with the equipment required for the activity.

The literature describes simulation group sizes within the range of 4–14 participating students [32, 34]. Whether the students participate by being directly involved in the simulation or by simply observing the scenario, their learning should not be affected provided that they all participate in the briefings and debriefings [11]. For the first two scenarios, groups of four OR nursing students alternated in pairs as simulating or observing students. This was repeated for the third scenario, this time including four nurse anesthetist students who were also alternating in pairs.

It is our belief that the best teaching practices evolve from the collaboration of collegial teams. A collegial team is characterized by two or more colleagues working in partnership toward a common goal. The collaboration develops through discussion and sharing of knowledge and experiences with teaching methods. The collegial team is creative, with colleagues challenging each other through critical reflection and views on pedagogical approaches [35].

This pedagogical teamwork makes the planning, implementation, and evaluation of learning activities interesting and professionally stimulating for teachers. Critical reflection within the collegial team requires a good working environment, with a culture of sharing and mutual respect between the teachers. Being a “critical friend” requires colleagues to be encouraging, as well as willing to identify and address problems that may occur, and to suggest different solutions and other ways of thinking [35].

5 The Prebriefing

Prebriefing may also be referred to as simulation orientation, introduction, or briefing [36]. It establishes what is to come by providing students with an overview of the learning objectives for the course and simulation exercise, as well as the knowledge required [37]. The prebriefing gives the students an introduction to the essential nursing skills needed for the scenario and an explanation of their expected performance [28]. The main objective of each scenario was to prepare the OR and patient for the upcoming surgery while using the non-technical skills described by the three categories of SPLINTS-no. The simulating students were prepared for their tasks in the prebriefing and were given an outline of their expected performance of non-technical skills (Fig. 2).

Fig. 2
A model of two horizontal and one vertical rectangle depicts the expected performance of scrub and circulating nurses in the simulation.

The expected performance of students in the simulation

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Students are more competent, self-confident, and satisfied with the simulation when provided with a structured prebriefing that includes practical information and a hands-on introduction to the simulation environment [38]. Students are also more likely to stay focused on the objectives of the simulation when the environment and equipment are known to them beforehand [13]. The prebriefings in this study were given on-site in the OR simulation laboratory and allowed the students to familiarize themselves with the simulation environment and equipment [37]. The students were encouraged to locate, touch, and examine the available equipment and simulation mannequin. They were given the opportunity to clarify any uncertainty regarding OR nursing skills, and the facilitator offered to demonstrate these skills on request.

Despite the accurate depiction of the OR environment in the simulation, students will still be conscious that it is a simulated environment, and it cannot therefore be guaranteed that they will behave in exactly the same way as they would if the situations were experienced in real life [34]. To step out of their comfort zone and willingly take on the roles allocated for the simulation, students are dependent on a sense of psychological safety. An effective prebriefing establishes a climate where students feel sufficiently psychologically safe to commit to the scenario, accept critical feedback, and welcome new ways of thinking in the debriefing [36]. The students were reminded of the confidentiality maintained by the group and were informed that the simulations would be livestreamed to their peers observing in the debriefing room. The simulations were not videotaped.

Literature describes prebriefings lasting from 3 to 5 min, as well as up to 45–60 min, depending on the duration of the simulation session and the level of detail required by students in the orientation [36]. The prebriefings took place immediately preceding the simulations. The first prebriefings were completed in 45 min. The prebriefings for the second scenario were shorter, as students may only require a quick walk-through between repeating simulations [36].

Establishing ground rules related to the simulation also helps keep learning focused [13]. The facilitator clarified simulation etiquette, norms, and roles prior to commencing and set clear boundaries and expectations [36]. The facilitator introduced the simulation by explaining the scenario and role of each student [28], as well as the beginning, end, and duration of the simulation [36]. The facilitator followed a prebriefing checklist to ensure that all important elements were covered (Fig. 3).

Fig. 3
A flowchart of nine boxes and arrows pointing toward the next step depicts the prebriefing checklist.

Prebriefing checklist—adaptation of the simulation prebriefing checklist from the Health Sciences Simulation Unit (EHS) at Norwegian University of Science and Technology (NTNU)

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6 The Simulation

OR nursing student groups of four spent 4 h on the simulation activity with the two single professional scenarios. Each student served as either simulating student or observer for the first scenario and then switched their role for the second scenario. Mixed groups of eight OR nursing and nurse anesthetist students participated in the interdisciplinary activity. This third scenario was simulated by half of the interdisciplinary student group; this half then became observers, while the other half of the simulating students repeated the scenario.

6.1 Expected Performance

Situation awareness is demonstrated by the ability to achieve the necessary awareness of a situation in a given context [39]. The OR nurse is expected to display situation awareness by checking the patient’s identity and obtaining necessary information from the patient [24]. To do this, the circulating nurse must take on a leadership role and perform the World Health Organization (WHO) Surgical Safety Checklist Sign In prior to induction of anesthesia for each surgical procedure. This involves checking the patient’s identity and consent, confirming the surgical site and procedure, and noting patient allergies and predicted blood loss during surgery [40]. Situation awareness is shown in collecting, recognizing, and understanding information from the surroundings by maintaining an overview of the continuously evolving situation in the OR. The OR nurse prioritizes tasks, shifting effectively between them, while taking into consideration verbal and nonverbal cues from other team members, as well as any changes in the patient’s needs.

Team familiarity can improve non-technical skills [41] and helps predict the needs of others [42]. Effective use of situation awareness skills can help predict what instruments and equipment might be required, coordinate requests and tasks with other team members [24], and encourage anticipation of what will, can, or should happen next. The team’s collective situation awareness is defined as “the degree to which every team member possesses the situation awareness required for his or her responsibilities” [43]. Team members seek a shared awareness of the situation with others in their team, when relevant to the performance of their own role [44].

Insight into other team members’ roles and functions, and an understanding of their tasks, increases effective communication between professionals in the OR [45]. Expedient OR nursing skills include communicating clearly and appropriately for the situation and using nonverbal communication when needed. The OR nurse provides and receives essential information in mutual exchanges with other team members, requesting clarification and displaying leadership skills when necessary [24]. These skills can prevent adverse events in the OR. The vigilance of the circulating nurse is critical for the prevention of potential errors, particularly concerning establishment and maintenance of the sterile field [46]. The OR nurse establishes and secures the sterile field, following knowledge-based OR nursing standards and encouraging others in the team to do likewise [25].

OR teams spend almost half of their time multitasking [47]. OR nurses are expected to communicate change, effectively prioritizing simultaneous demands from other team members and reacting appropriately to interruptions. They are essential in providing support by offering help and assistance, giving positive feedback, contributing to a calm atmosphere in the OR, and delegating tasks to reduce stress [24]. The main task for the OR nursing students in all three scenarios in our simulation was to prepare the patient and OR promptly for the upcoming surgical procedure while displaying non-technical skills. Failing to adequately plan the preoperative preparations has been shown to have a negative impact on OR team performance, making breakdowns in both the coordination of tasks and team communication more likely [48]. OR nurses should prioritize tasks, making efficient use of time and opportunities to prepare for the next step whenever possible [24].

6.2 The Observers

The OR nursing students who were observing the simulation used the behavioral rating measurement system SPLINTS-no to assist them in identifying what skills to look for and how to describe them. Following the prebriefing, the observers entered the debriefing room, where they watched a livestream of the simulation and were asked to take notes according to each of their allocated tasks as observers: What would I have done if I were to participate in the scenario? Would I have done the same? Why? Would I have done anything differently? If so, how and why? It is helpful to observe the actions and events that occur in simulations through a common predetermined list of non-technical skills [39], and the observers used the behavioral rating measurement system SPLINTS-no to assist them in identifying what skills to look for and how to describe them. The debriefing room was accessible only to the students and teachers involved in or observing the simulation, thus ensuring the confidentiality of the exercise [32, 49].

6.3 The Facilitator and the Simulation Technician

During the simulations, the simulation technician was situated in an adjoining or remote room, connected to the simulation laboratory through audio and video. The simulation technician was responsible for voicing the patient remotely and was therefore able to adjust the patient’s verbal responses to the actions taking place. For the third scenario, the nursing mannequin was replaced by an advanced high-fidelity simulator, allowing the simulation technician to adjust vital physiological responses and monitor parameters in response to the actions of the students. The simulation technician was connected to the facilitator with a headpiece, making direct and discrete communication with the facilitator possible for the duration of the simulation.

The facilitator and simulation technician both observed the simulations for significant events related to non-technical skills. They compared notes directly following the scenario, before continuing to the debriefing stage. These notes could then be used in the debriefing if necessary [50].

7 The Debriefing

Literature on this subject agrees that a debriefing session using a systematic approach encourages reflective learning, when planned well [13, 32, 49]. Debriefing models advise focusing on the preset objectives of the simulation [32, 49] and using a structured approach rather than informal discussions to promote reflection and learning at this stage [32, 33, 49]. It is important that teachers feel confident with all elements of the simulation activity, in order for the students to benefit most from this exercise [13].

Directly following the simulation, the simulating students were asked not to discuss their participation in the scenario until they were joined by the observers for the debriefing session. The structure of the debriefings was based on Steinwachs’ debriefing model [50], which all teachers involved had been familiarized with during facilitator training. The facilitator guided the students through the three phases of debriefing: description, analysis, and application (Fig. 4).

Fig. 4
A model depicts three phases of debriefing, labeled as description, analysis, and application.

Three phases of debriefing, adapted from Steinwachs [50]

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Steinwachs describes the debriefing session as “a structured, facilitated conversation with the primary goal to encourage the students to share their reflections in order to discover together” [50]. The facilitator should begin the debriefing by reiterating the learning goals of the activity and avoid lecturing the students on what they should have done in the simulation. The facilitator’s role is to be a good listener and stimulate conversation, allowing the students to share their experiences, perspectives, and understandings with their peers. In our simulation teachings, the facilitator helped the students stay focused on non-technical skills throughout the debriefing and ensured a balance of speaking time for both the simulating students and the observers. The SPLINTS-no system gave the students a common language for non-technical skills relevant to OR nursing, which assisted them in identifying issues from the simulation relevant to the learning objectives for the simulation activity. Together, the students analyzed the events of the simulation by taking turns to describe what they observed. They examined issues that occurred in the simulation, gave feedback, and drew parallels between what they learned from the simulation and potential future applications of this knowledge [50].

7.1 Ethical Considerations

The students were informed that their answers to the questionnaire could be used for development and research. The data material was not linked to any IP addresses or other identifying information, and correspondence with the Norwegian Centre for Research Data (NSD) confirmed that using the data for this study attended to the participating students’ anonymity.

8 Evaluation

Following the simulation, the collegial team held a structured evaluation meeting to discuss the simulation activity. The success of the simulation planning, briefing, and level of student preparedness were evaluated, and the level of student engagement and effective learning in the debriefing session was used to determine the success of this pedagogical learning method. The students’ perspective is essential for the teacher’s evaluation of simulation exercises as a successful pedagogical method for achieving learning outcomes and to justify the extensive use of resources required to run the simulations.

To receive feedback on the simulation activity, it is essential to evaluating the students’ learning outcomes [13]. To assess whether the OR nursing students enjoyed the training and felt it was valuable to their learning, the Debriefing Experience Scale [51] was prepared as an anonymous, secure online questionnaire. The questions were provided as a Norwegian translated version [52] and answered on a scale consisting of five options that ranged from strongly agree to strongly disagree. The students were granted access to the questionnaire after the third simulation activity was completed. Excerpts from the results are illustrated in Fig. 5.

Fig. 5
A bar graph depicts the percentages of debriefing experiences from students' perspectives. It is categorized into agree, neither, and disagree.

Debriefing experience

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The students’ responses indicated their subjective experiences of the simulation exercise with respect to their reactions and learning (knowledge, skills, and attitude). These are the first two levels of simulation evaluation, according to Kirkpatrick’s widely used model of training evaluation from 1959 [53]. Kirkpatrick’s next two levels of simulation evaluation—impact (change in behavior over time) and results—were not evaluated in our questionnaire. The results from the questionnaire revealed that most of the students agreed or fully agreed that the three phases of debriefing were helpful and rewarding.

9 Conclusion

Three scenarios of presurgical preparations in the OR were simulated, each of which was followed by a facilitated three-phase debriefing session. These debriefing sessions were pedagogically grounded in the three intertwined dimensions of education: qualification, socialization, and subjectification. They helped the students analyze their thoughts and provided a structure for reflection, encouraging them to make connections between theory and real-life situations in the OR that involve autonomous decision-making. The SPLINTS-no behavioral rating tool was used for reflection and learning throughout the pedagogical activity, providing the students with a common language for feedback, analysis, and reflection. As a pedagogical activity, simulation of non-technical skills in the preoperative OR can be rewarding for OR nursing students. Learning outcomes can be achieved using both low- and high-fidelity simulations, provided that they are identified clearly to all involved and that the activity is planned effectively.