Medical

Communication

Biosci. Biotech. Res. Comm. 10(3): 542-550 (2017)

Perceived challenges by the Iranian baccalaureate

surgical technology students in their clinical education:

A qualitative study

H. Karimi Moonaghi

, R. Zardosht

*, M. Etezad Razavi

and S. Ahmady

Ph.D Nursing Education, Associate Professor, Evidence-Based Caring Research Center, Department of

Medical-Surgical Nursing, School of Nursing and Midwifery, Department of Medical Education, School of

Medicine, Mashhad University of Medical Sciences, Mashhad, Iran

Student Research Committee, School of Nursing and Midwifery, Mashhad University of Medical sciences,

Mashhad, Iran

Eye Research Center, Khatam-al-Anbia Hospital, Faculty of Medicine, Mashhad University of Medical

Sciences, Mashhad, Iran

Faculty of Medical Education, Shahid Beheshti University of Medical Sciences, Tehran, Iran

ABSTRACT

The operating room  eld in Iran is a branch of medical sciences during this period, students became become familiar

with the new principles of the operation room and modern surgical techniques in specialized and super specialized

surgeries and they train the care and assistance to the patient’s administration before, during and after operation. The

purpose of this qualitative study is to investigate how the students are taught, the effective factors and possible chal-

lenges related to educational issues in the operating room. This is a qualitative content analysis which was performed

in 2014-2015. The participants consisted of 35 bene ciaries in the operating room  eld, namely, students of different

academic terms, matrons, educators (instructors), surgeons and operating room personnel in different academic cent-

ers in Khorasan Razavi province who were rich in information and had a tendency to comment on their experience.

In this study, sampling was  rst carried out in a targeted way and then was continued with theoretical sampling

and sampling was continued until data saturation. All interviews were recorded and then handwritten and analyzed

using continuous comparative method and qualitative content analysis. The profound and deep descriptions of the

participants led to the emergence of 13 subcategories and 3 main categories of the “unconventional educational

atmosphere”, “the challenge of student admission to the surgical team,” the “operating room culture” and,  nally,

542

ARTICLE INFORMATION:

*Corresponding Author:

Received 21

June, 2017

Accepted after revision 27

Sep, 2017

BBRC Print ISSN: 0974-6455

Online ISSN: 2321-4007 CODEN: USA BBRCBA

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Online Contents Available at: http//www.bbrc.in/

DOI: 10.21786/bbrc/10.3/31

H. Karimi Moonaghi et al.

BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS PERCEIVED CHALLENGES BY THE IRANIAN BACCALAUREATE SURGICAL TECHNOLOGY STUDENTS 543

one main theme of the “dynamic nature of the operating room”.The special educational environment in the operat-

ing room environment, lack of acceptance of students in the surgical team as a training member and hierarchical

culture of the operating room, has created problems for the training of these students. In fact, the clinical training of

operating room students is based on teamwork and the members of the surgical team are, in some cases, instructors

in the shade. Given the dynamic nature of the operating room, collaboration and participation between educational

and clinical institutions can help improve the learning environment, acceptance students in the surgical team as a

training member, and creating a dynamic, collaborative and  exible culture.

KEY WORDS: PERCEIVED CHALLENGES IRANIAN BACCALAUREATE SURGICAL TECHNOLOGY STUDENTS

INTRODUCTION

Bachelor of Science in surgical technology in Iran is a

branch of medical science during which the students

become familiar with new principles of surgical tech-

nologies in specialty and subspecialty surgeries and they

learn how to care and help the patients before, during

and after surgery (Operating Room and Anesthesia,2017).

Training programs of operating rooms are offered in

two ways worldwide: in the  rst case, nursing gradu-

ates (after achieving a bachelor’s degree) are trained in

a period of 1-2 years to enter the operating room. In the

second case, surgical technicians, after general training

of the operating room, are prepared to act as a mobile

and scrubs and then, if desired, they are prepared as the

 rst help of the surgeons in a period of 1/5 to 2/5 years.

Standards of patient care in the community of operat-

ing room nurses in America also show that students of

operating room technician can pursue their education

in specialized courses in higher education. The people

of each period have their own duties and the role of

these specialized people is different from the operating

room technician. Operating room is a complex system

that coordinates the individual, technology, and patients

in a physical environment to achieve favorable out-

comes in patients (Islamic Republic of Iran Ministry of

Health and Treatment and Medical Education Supreme

Council for Planning of Medical Sciences, 2007). Oper-

ating room is considered as high-risk environment for

patients, because in spite of the small number of cases,

some potential problems of patients after the surgery are

due to the mistakes of the operating room personnel that

can lead to the death of the patients (Deyoung 2009).

In Iran, students of surgical technology are admitted

directly based on the exam and with no relation to nurs-

ing. This  eld, in different colleges between the years

1987 to 2001 and it was launched at the undergraduate

across the country, was launched in the associate degree

level in 2009 (Operating Room and Anesthesia, 2017).

Due to the fact that now in Iran there is no training

courses in doctoral degree (Ph.D.) for surgical technol-

ogy and its MA was launched only two years ago, MS

nurses in internal injuries (with work experience in the

operating room or an associate degree in surgical tech-

nology) take the responsibility of the practical and theo-

retical training of this group of students in educational

centers. Given that the  eld is new and considering the

volume increasing of training centers for students, it is

not considered the required infrastructures such as spe-

cialist human resources in clinical training and educa-

tional facilities in proportion to the number of students.

There is not enough number of teachers in the  eld,

so in many centers teaching this group, traditionally,

is given to the supervisors and operating room person-

nel. Subsequently, due to lack of necessary knowledge of

educational affairs, students have faced with problems

in their training (Bahrami et al 2014).

The purpose of the training is the optimal and effec-

tive care of patients before, during and after the sur-

gery especially in the specialized surgeries, control and

prevention of nosocomial infections as well as creating

the perfect mental conditions for patients and proper

maintenance of devices and medical equipment (Islamic

Republic of Iran Ministry of Health and Treatment

and Medical Education Supreme Council for Planning

of Medical Sciences 2007). However, some items such

as technical approach to the  eld, high expectation of

the graduates in this  eld to help surgeons, and sepa-

ration from nursing have caused the graduates to not

have enough knowledge of nursing care of patients

before and after surgery as well as communication with

patients. So, they have just learned the technical skills

during the surgery (Bailey 2010).

Foreign countries’ researches have reported about

training in the operating room which is connected with

the collaboration (Silen-Lipponen et al., 2004) stress,

communication failures (Laur et al., 2012), the effect of

stress on other members and students (Kenton 2006) and

to the development of the group of Skoczyl et al. (2005).

The difference in the education of graduates of the sur-

gical technology in Iran and other countries has caused

the results of the studies in the  eld to be inapplicable

in the country. Unfortunately, there is not extensive and

ef cient research in the surgical technology in the coun-

try. Conducted researches are quantitative and investi-

gate certain aspects of education in surgical study. So,

H. Karimi Moonaghi et al.

544 PERCEIVED CHALLENGES BY THE IRANIAN BACCALAUREATE SURGICAL TECHNOLOGY STUDENTS BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS

they are not able to analyze all aspects of education in

the surgical technology (Bahrami et al., 2014; Khazaei

et al., 2014, Tazakori et al., 2016).

However, qualitative approaches have holistic

approach to the phenomenon and gain precious informa-

tion about the training in the clinical environment. The

aim of this qualitative content analysis is the evaluation

of teaching the students, their required skills, effective

factors and potential challenges associated with educa-

tional issues in the operating room. Planning to elimi-

nate the defects of the  eld improves the knowledge and

skills of students in this  eld, provides better care for

patients, and ultimately improves the health system.

MATERIAL AND METHODS

The study is a qualitative content analysis study (part

of a larger study). It was conducted in 2014-2016 to

reveal the problems and challenges of education in the

 eld of surgical technology in Iran. The environment

includes all the operating rooms of educational hospi-

tals of Khorasan Razavi (Mashhad, Nishabur, Torbat Hei-

darieh and Gonabad). The interview was done in places

that are accessible to participants or places they desired.

The participants were 35 of bene ciaries of education

in surgical technology such as the students of differ-

ent academic semesters, head nurses, teachers, surgeons

and operating room personnel at various universities in

Khorasan Razavi province. They have precious informa-

tion and they were willing to recount their experiences.

Sampling was done by using purposive sampling and

continued by theoretical sampling. Some of the charac-

teristics of the participants are as follows: willingness

to participate in research and express their experiences,

students who had spent at least one training courses,

educators who had at least a year of training in the oper-

ating room, and operating room personnel who had at

least one year of work experience in the room.

Data were collected by using semi-structured indi-

vidual interviews. The interview was started by general

questions regarding the interview directory and was

guided by the responses of participants. After explaining

the objectives of the plan to participants and obtaining

informed consent, data collection was began. The main

question were as follows: what makes you to call a day

of the training as good and useful? Or feel the training

is not of enough interest today? Mention a good expe-

rience and a bad experience from your training in the

operating room? What are the facilitating and impeding

factors in your clinical training?

A total of 37 interviews was carried out (35 initial

interview and two follow-up interviews). The study

continued from Tir 93 to Azar 95 (Iranian year). The

researchers tried to consider the maximum variation in

the sampling; (14 students, 6 Operation room person-

nel with associated degree or BS in surgical technology

or BS in nursing, 4 operating room heads, 6 training

teacher, one Dean of the Faculty, 3 surgical assistants

and one surgical staff). Educational centers of Khorasan

Razavi included Mashhad, Torbat Heydarieh, Gonabad

and Nishabur. Data were analyzed according to conven-

tional content analysis.

The data analysis was based on Graneheim and Lun-

dman in seven steps (Graneheim and Lundman 2004).

In the  rst step, all interviews were recorded and tran-

scribed. Then, the decision made about the analysis unit

and before starting the coding process, text of interviews

was read several times as the unit of analysis. Mean-

ing Units were also read and reviewed several times and

unrelated statements were deleted. First, some units were

de ned and relevant codes of each Meaning unit were

written and then the codes were classi ed inductively

and based on common sense and meaning.

The process of data reduction was continued in all

units of analysis and primary and secondary classes. In

other words, subclasses with similar events are grouped

together as classes and then primary classes formed

and this trend continued up to the theme. It should be

noted that during the analysis the necessary changes

were done in the name of the classes which must show

the content of the class. The analysis was continually

conducted by adding up each interview and the classes

were modi ed. To simplify the process of data analysis,

ParticipantsNumberAgeGender

Work experience in the

operation room

Student1422-2011 females/3 malesSemester 4 to 8

Training teacher648-355 females/1 male3-20 years

Operating room personnel655-325 females/1 male8-25 years

Dean of the Faculty152Male-

Assistant348-32

Chanbge this year to

English Calender Male

4-5 years

Staff153Male17 years

Operating room head455-32Male15- 29 years

H. Karimi Moonaghi et al.

BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS PERCEIVED CHALLENGES BY THE IRANIAN BACCALAUREATE SURGICAL TECHNOLOGY STUDENTS 545

coding, cataloging and classi cation, comparing various

data frequently and retrieving quotes, we used software

MAXQDA 10 (Mayring 2000).

To increase the reliability and validity of the results,

we used the methods used by Cuba and Lincoln that

were quoted by Polit and Hungler. The two research-

ers consider the four criteria of con rm ability, cred-

ibility, dependability and transferability as necessary for

the consistency and strength of qualitative data (Burn

and Grove 2007). Therefore, researchers have helped to

validate data with continuous involvement with data,

data veri cation by the participants, allocation of suf-

 cient time to the study and open communication and

empathy with the participants. In order to determine the

dependability, two separate research teams coded the

Interviews that there was a high degree of agreement

(85%) between the comments. Also, great care was done

in the collection, implementation and recording of data

and allocating of enough time to collect the data. As

for the transferability, manuscripts, interviews and units

of analysis with extracted initial codes were provided

to participants and the necessary corrections made and

the proposed points were considered. In addition, three

expert in the  eld of qualitative research monitored the

study. Using a combination of methods (interviews and

 eld notes) as well as sampling with maximum diversity

(interviews with students of different academic semesters

from different training centers, faculty-member educa-

tors, non-faculty member educators, and surgeons with

different expertise) have increased the con rm ability

and transferability of the data. In addition, describing

the studied background, providing necessary explana-

tions about the participants and using of their direct

quotations was also done in this regard.

Ethical considerations in this study include: obtain-

ing ethical permits from Committee for Medical Research

Ethics of Medical Sciences of Mashhad (ethical code

940548), explaining the purpose of the study and the use

of tape recorder, explaining the way of collecting data

for the participants and satisfying them to cooperate,

obtaining consent in writing for conscious participation

and paying attention to the basics including the research

explanation, identifying the purpose of the study, stat-

ing the criteria for sample selection, the bene ts of

participation in the research, ensuring the anonymity,

answering questions, the right to refuse to continue the

research, providing adequate information and assuring

the participants to put the interviews in a safe place.

RESULTS AND DISCUSSION

Data analysis of participants’ statements and notes in

the  eld lead to the emergence of 12 subcategories and

3 main categories and eventually one main theme.

Main category: unconventional educational atmosphere

This category includes the following subcategories: lack

of facilities and trainers, lack of balance between train-

ings and goals, red lines, safety and sterility principals,

the confrontation of the caring and technical roles of stu-

dents and the simultaneous presence of other students.

Lack of facilities and teachers: learning environment

has been considered as a key environment for education

and training of students and for helping to link theory

with the practice in the clinical setting. The data in this

study showed that the participants are not satis ed with

their learning environment. A training teacher with sev-

eral years of experience in the operating room, says:

”In the classroom sometimes it is required to explain

or draw a part of something and there is no whiteboard

and facilities there. There is no place for equipment and

SubcategoryMain categoryMain theme

Lack of facilities and teachers

Unconventional educational

environment

The dynamic nature of operating room

Lack of balance between training and goals

Red lines, safety and sterility principals

The confrontation of caring and technical roles of students

The simultaneous presence of other students

Annoying students and reduction of team speed

Challenge to admit students to the

surgical team

Lack of required knowledge and skills

The absence of the trainer and humiliation of the students

Teamwork

Operating room culture

Gender discrimination

Hierarchical structure (physicians governorship)

Paradox of Professional interactions and inappropriate interactions

Duality of behaviors and the absence of legalism

H. Karimi Moonaghi et al.

546 PERCEIVED CHALLENGES BY THE IRANIAN BACCALAUREATE SURGICAL TECHNOLOGY STUDENTS BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS

relaxation of students and it seems as though they do

not have facilities for us”. The conversion of associate

degree to bachelor and the increase of the number of

students regardless of the required infrastructure have

created problems. The operating room head who has

been in charge of training courses says: “The teacher

cannot afford to train the students due to the increas-

ing number of students as well as the presence of stu-

dents from semester 4, 6, 8,”. A student says:” teachers

cannot teach us everything and do not have time to do

so”.In educational centers of cities other than Tehran,

students actually cannot see thoracic and cardiac sur-

geries, advanced neurological and eye surgery. “Due to

the low number of operating rooms and lack of variety

in surgeries, the trainings in the cities are the same and

students see the same surgeries in the semester 8 that

had seen in semester 2”

Lack of trainers: it is hard to understand the routine

and special procedures of hospitals for educators who

temporarily go to the hospital with students. Absence

of the trainer or the use of non-professional teachers or

staff have affected the clinical training of surgical tech-

nology students. A student says: “When we do not have

any trainers, the only thing is the attendance. Then, they

told us to go to the rooms and it is not important to

learn or not to learn”. In multiple studies, students’ con-

fusion and uncertainty in the absence of the trainer has

been reported as factors causing problems.

“Of course, depending on the hospital, when we do

not have trainer and the nurse is responsible for check-

ing, there is no problem if we are late. I do not remember

any washing. Because we do not have  xed trainer, they

do not have us to do morning washing.

Mismatch between educational objectives and

training objectives: Data analysis showed that the stu-

dents complain about the aimless trainings and they

consider the lack of transparency in goals and evaluat-

ing the training as a major problem. A senior student

says: the lesson plan is originally for apprenticeship and

they should it to students to understand what they do.

In fact, I mean that we should be given a sheet based on

which they evaluate us. I have not seen anything and

most professors evaluate us based on scrub “Students

considered as useless some training courses including

recovery or management trainings. A student says: “We

have weaknesses in  le writing and recording of HIS

and I personally cannot do this. At least they should

include this in training courses. “A student told about

the lack of training in Laparoscopy: “I went to the room

for laparoscopic surgery and it was cholecystectomy. I

did not know anything about laparoscopy even the the-

ory. The personnel came and taught me quickly.

Red lines, safety and sterility principals: the operat-

ing room is a complex system in which an individual

coordinates the technology and patients in a physical

environment to achieve optimal outcomes in patients.

Data analysis showed that the majority of operating

room personnel are sensitive to safety and sterility prin-

cipals of patients. A personnel says:

“If we told them to cover your hair, they would think

it is because of Hijab but it is not and if the hair go to

the sterile  eld, it can cause infection and problems for

patients. Although we notify them, they hate. The health

is important here and you can be as you will out of

here. And you have to comply with the rules and stand-

ards here.” On the other hand, surgeons also have their

own reasons for patient safety: “The patient has trusted

the surgeon about his life and the decision maker is the

surgery team. Survival is not interchangeable with any-

thing. It is not acceptable to put the life of the patient

in danger.”

Confrontation of caring roles and technical roles of

students: in the operating room environment, compared

to the other sectors, a speci c aspect of care is mostly

emphasized that is technical. One of the participants

says:”If we look at it as a scienti c discipline, we must

go beyond the skills and consider it as theory-based

thing. The problem here is that it seems most of the

duties designated for the graduates of this  eld is practi-

cal, but this  eld is subdivision of the Nursing Science.

The thing that now is happening is the technical look at

the graduates of the  eld. So, they are expected to know

the equipment and to help the surgeons in the surgery.

Simultaneous presence of students from other

disciplines: the difference in the type of training and

simultaneous activity of surgical technology and other

students and operating team make the operating room

training more different and dif cult than other parts

of the hospital. Faculty member trainer with 14 years

of experience in training in the operating room says:

“Simultaneous presence of students with different lev-

els of training from freshmen to residents and even the

professor himself in a place leads to different clinical

experience in the place and the students cannot keep up

with the situation and it is dif cult to them.

Second category: the challenge of admitting the

students in the surgical team

This category includes annoying students and the reduc-

tion of the team speed, lack of the required knowledge

and skills of students, the absence of the trainer and the

humiliation of students. Data analysis showed that the

surgeon believes in the priority of patient safety and the

life rather than the training and he/she seeks a surgery

with minimal side effects for the patient.

Annoying students and the reduction of the team

speed: an operating room personnel in this regard

says:”The students are beginners and annoying. The

H. Karimi Moonaghi et al.

BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS PERCEIVED CHALLENGES BY THE IRANIAN BACCALAUREATE SURGICAL TECHNOLOGY STUDENTS 547

personnel’s works are rapid and easy, but it is not the

same for students. They stand there without doing any-

thing even when the assistant wants to move to the

other place. Another trainer says:”Students in the oper-

ating room are uninvited guests and physicians and sur-

geons are sensitive to the students. Unfortunately, I’m

concerned about the students and I permanently turn

around in their room and it leads to sore feet because

there is no place to sit.

Lack of required knowledge and skills of students:

Interview with operating room assistants showed that

admitting the students in the surgery team causes some

problems.”We had a student that knew no equipment. In

the middle of the surgery we had to change him because

it was a two hour surgery and we were just cutting the

area without doing anything. He had lowered our speed

and we had to change him.

Absence of the trainer and the humiliation of students:

a student says:

“When we did not have the trainer, the personnel took

the responsibility and the only important thing was the

attendance. Then we were told to go to the rooms and it

was up to us to learn or not to learn. “I thought that I am

a useless creature that gets humiliated and the students

were blamed for any mistakes.”

Or another student talks about the impact of every

single person on the admission of the student in the

team: “The surgery began and we wanted to go to the

room, but the surgeon did not allow. As I said it depends

on the surgeon and other factors and all of these are

effective in our training.

Third category: The operating room culture

This category includes teamwork, gender discrimination,

hierarchical structure (surgeon as the governor), paradox

of professional interactions and inappropriate interac-

tions, behavior duality and lack of rule of law.

Teamwork: Since the operating room environment is

of interactive and dynamic nature, to make the surgery

team more cooperative and to eliminate the confusion of

the students in the room, the clinical education program

of the students should be transparent for the operating

room personnel. Some operating room personnel do not

consider the participation in the training as a part of

their duties and even disappoint the students and the

trainers with inappropriate behavior and create an unfa-

vorable atmosphere. However, some staff play the role of

the trainer for the students. “Most guys say that the edu-

cator plays an important role in the training. However,

I say some personnel are the trainers of the students

and they explain for you the techniques step by step in

the operating room. Faculty member instructor with 14

years of work experience in training says: “See! It is a

teamwork and each and every member of the operating

room can have clinical effect. Perhaps the least role is

for the head nurse and the personnel in the room have

the greatest role in training students.

Gender discrimination: One of the known causes of

stress in operating room environment for students is the

others’ behavior.”A senior student says: unfortunately,

some personnel or male surgeons work with female stu-

dents. I like justice not discrimination. It is not fair to dis-

miss the female students earlier than males. If the female

students cry, the personnel and the surgeon will change.

Hierarchical structure (doctor as the governor)

researchers believe: a good clinical setting has non-hier-

archical structure in which the works are done in teams

or groups and there is good communication. A trainer

says:”Look! When you have a pretentious assistant who

does not know his work well and says I’m very good and

am in a hurry, he does not let the students use the equip-

ment correctly. He watches the student carefully. How-

ever, a patient assistant says take your time we are not in

hurry and even tells anesthesiologist that we need more

time. Unfortunately, we don’t have many of this surgeons

and you have to have a chance to work with them.

Paradox of professional interactions and inappro-

priate interactions: To make a team work so ef cient,

team members should be familiar with their capabilities.

This leads to appropriate interactions between them and

coordinates them. The trainer says:”Even students work

more with good communicators. He might not be well in

the knowledge, but he is good at communication. When

he graduates, he is better than a good student with weak

relationship and this is important. One of the operating

room personnel in connection with the close interaction

in the environment of operating rooms says: “some stu-

dents abuse this open communication and some of them

do not have the capacity of such communication.

Studies have shown that in a good clinical setting

the interactions are not top-down and the work is done

interactively. Data analysis and statements from stu-

dents and educators in this study shows that surgeons

have a top-down look to surgery team especially sur-

gical technology students. This behavior is not in the

framework of the operating room rules.”Unfortunately,

in Iran the higher the education, the higher the immo-

rality and higher education leads to higher immorality.

Behavior duality and lack of rule of law: in the status

quo operating room personnel do not consider the coop-

eration in training as their duty. And they do not have

necessary cooperation with the trainer for providing

the required facilities to students and transferring their

experiences in the absence of the trainer.”The student is

of no position and is blamed for everything wrong even

it is the fault of the personnel. Another trainer about

the ignorance of some surgeons says:”According to the

H. Karimi Moonaghi et al.

548 PERCEIVED CHALLENGES BY THE IRANIAN BACCALAUREATE SURGICAL TECHNOLOGY STUDENTS BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS

rules of the school we took a male student to the women

operating room. The gynecologist of the room began

to quarrel and said to force the student out. Another

trainer in connection with the operation room atmos-

phere says:”There is no law here. If there is a law, they

can be persecuted. However, doctors are the governors

and we cannot blame them.

Results of the study show that the challenges of clini-

cal education in the operating room in Iran, due to the

complex and dynamic nature of operating room, are

as follows: special educational environment, problems

of admission of the students as a member of the surgi-

cal team in operating room, and different culture of the

operating room. By comparing these, we can say that the

certain circumstances, difference of the operating room,

a shortage of faculty member in the department, and less

control of the trainer in the clinical environment of the

operating room have affected the training opportunities

of students in this  eld.

Operating room (OR) clinical practice involves special

contextual elements related to the preoperative nursing

process, practical OR nursing skills and teamwork in dif-

ferent patient care situations. However, the OR is one of

most inaccessible places in a hospital where the use of

space is highly regulated. Areas of space are divided into

unrestricted, semi restricted and restricted sections, and

the physical activities performed within each of these

designated areas are differentiated (Riley and Manias

2002). Working conditions for graduates of surgical

technology is different than those of other nurses. He is

forced to comply with a variety of procedures and high

workload quickly and carefully. Due to the quick entry

and exit of patients, his work is not expectable and in

many cases he is faced with acute and emergency situ-

ations and concurrent interactions with members of the

surgical team. It can harden the clinical education of the

students (Farneya et al 2013).

Because of the special atmosphere of the operating

room compared to other sectors, it seems that there is

more emphasis on the students of the  eld in techni-

cal skills and speci c approaches of the care. In Khaz-

ayi’s study (2015) about the clinical education of sur-

gical technology, the students gave the highest points

to the learning opportunities and the lowest points to

the performance of educators and educational facilities

(Khazaei et al 2014). The high point to learning oppor-

tunities is due to the favorable reception in parts that

were faced with shortage of human resources and the

students played the role of assistance in these sectors.

In the study of Ghorbanian et al.(2014), the most impor-

tant weaknesses of clinical education of operating room

are as follows lack of using teaching aids, inadequate

number of patients for learning, lack of knowledge of

students of clinical evaluation system, lack of adequate

oversight on the clinical education and lack of decision-

making power of the student in planning the care of

patients (Ghorbanian et al., 2014).

These are consistent with the contents obtained in

our research. In the study of Dehqani et al (2007), the

absence of proper scienti c grounds, lack of interest in

the students, confusion and uncertainty of the students

in the absence of the trainer were mentioned as factors

causing problem for training process (Dehghani et al.,

2005). Omidvar et al in Babol University of Medical Sci-

ences also considered the problems of clinical education

related to health centers’ personnel and their knowledge

(Omidvar et al. 2005).

In a similar study by Hadizadeh et al., it was found that

the understanding and cooperation of the health centers

staff is important in the educational process (Hadizadeh

et al., 2005). Providing diverse learning opportunities,

receiving proper feedback from trainers as well as clinical

environment are the important and effective factors of

clinical training in the other country’s studies (Andrews

et al., 2006 and O’Driscoll et al., 2010). The results of this

study showed that due to the special circumstances of the

operating room, the admission of the students as a surgi-

cal team member has faced with dif culties.

Qualitative research of Lingard et al (2002) showed

that the communication models in the operating room are

complex and socially-motivated. The predominant themes

include, time, security, sterilization, resources, roles and

conditions. Often, every procedure had 1 to 4 stressful

incidents and the stress transferred to other team mem-

bers or the environment. In response to the tensions, the

trainee of the operation was separated from the surgical

team or began to mock. Both of these reactions are nega-

tive indicators for the team communications. The results

are consistent with the study of Lingard et al (2002).

Tanner and Timmons (2000) emphasized that behav-

ior in the OR is different from that in other hospital areas,

and that the OR could be described as a ‘backstage’ area.

In a backstage area interaction includes joking, talking

about aspects of private life and behaving in a famil-

iar manner. It also includes gossiping and disrespectful

talking, even about patients during narcosis, which was

also mentioned in this study. Frontstage behavior is the

absence or opposite of this and occurs in the or when

the patients are conscious before anesthesia or in the

recovery unit (Tanner and Timmons 2000).Perhaps this

antagonism between backstage and frontstage behaviors

explains the students’ excitement and frustration in the

OR. Usually, before their OR placement period, students

have spent time in frontstage areas, have dealt with staff

more formally and have had closer caring relationships

with patients. In addition, some nursing students have

previous experience of patient care before enrolling in

H. Karimi Moonaghi et al.

BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS PERCEIVED CHALLENGES BY THE IRANIAN BACCALAUREATE SURGICAL TECHNOLOGY STUDENTS 549

the programme (Manninen 1998 (which probably makes

their views about nursing more frontstage-oriented

In this study, participants have considered the admis-

sion to the surgical team as a gateway to opportunities

for learning clinical skills and using experience of team

members. However, the admission has its own problems.

In the study of Tazkori et al (2015), issues related to

clinical education in the operating room are as follows,

the lack of proper planning for training period, lack of

trust in teachers, lack of  exibility in the face of criti-

cism and non-compliance with professional ethics and

lack of taking time for clinical and educational consul-

tation, lack of learning opportunities in hospitals, lack

of familiarity with the described tasks of the students. In

Liponen’s study (2004) which was conducted as descrip-

tive phenomenology associated with the clinical set-

ting of operation room, three types of teamwork were

reported from the point of view of students:

Three types of teamwork emerged based on the stu-

dents’ perceptions: functional manifestation of OR

teamwork, gaining OR team membership and technical

orientation of OR teamwork. The  ndings are discussed

in relation to OR practice, education and research on

ways to improve teamwork while maintaining a satis-

factory OR learning context and stimulating interest in

perioperative nursing). (Silen-Lipponen, et al 2004) The

implications of this study is consistent with the  nd-

ings of our study. In another study that was conducted

in Bushehr University of Medical Sciences, the results

showed that the students consider the lack of learning

opportunities as one of the educational barriers (Abidi

and Motamed 2011).

Although working in the operating room is a team-

work and it needs participatory culture, the results of

our study showed the hierarchical culture in the clini-

cal setting of the operating room and the surgeon is

the commander and decision maker and sometimes he/

she loses the students’ learning opportunities. Sadeghi

et al (2011) believe that a weak and in exible culture

in the organizational environments causes employees

not to tend to the innovation, change and creating new

ideas and they fear from knowledge sharing. However, a

dynamic, collaborative, and  exible culture reacts well

to changes and leads to the progress (Sadeghi,,2011).

As studies show, participation and support from

staff increase the learning opportunities for students

(Heshmati et al2012). The results of another qualitative

research (2004) showed that about 30 percent of the

team transactions are faced with communication failure

and cause problems. One-third of the cases associated

with increased cognitive load (information processing in

short-term and activated memory), interrupting the pro-

cedure, increased tensions and jeopardizing the safety of

the patients (Zeighami et al 2004). However, Heshmatis

study showed that nursing instructors use strategies like

skills, realism, responsibility, determination, humility

and using the experiences of nurses to attract the col-

laboration of clinical staff in providing clinical trainings

(Heshmati 2012). However, other studies in our country

showed that the nursing teachers have problems in play-

ing their educational role (Heshmati et al 2010).

As stated by participants in this study, despite the

difference and stressfulness of the clinical setting and

its effect on clinical education of the students, participa-

tion and cooperation of every member of the surgical

team can enhance the quality of the clinical skills of

the students and this cannot be achieved unless in envi-

ronments with supportive and participatory culture.This

qualitative study was part of a larger study considering

restriction of the studies with qualitative methodology;

Such as: the subjective nature,  eld-based and their low

level of generalizability. Despite these limitations, the

results of this study provide deep understanding about

the nature of clinical environment of the operating room

and the problems related to clinical education of stu-

dents of surgical technology.

CONCLUSION

According to the  ndings of this study, the unconven-

tional educational environment in operating room, non-

admission of the student in the surgical team as an edu-

cational member, and hierarchical culture of operating

room have caused problems for these students. Since the

work in the operating room is collaborative and con-

current, control of this clinical learning environment is

dif cult. In fact, clinical education of the surgical tech-

nology students is team-based and all members of the

surgical team are, somehow, trainers in the shadow. Due

to the dynamic nature of the operating room, coopera-

tion of educational and clinical institutions can improve

educational environment, admission of the student as an

educational member in the surgical team, and creating a

dynamic, collaborative and  exible culture.

ACKNOWLEDGEMENT

This study is part of a larger study and extracted from

a doctoral dissertation. Writers appreciate all the great

professors who provide the research facilities as well as

Deputy Minister for Research and Technology of Mash-

had University of Medical Sciences for  nancial support.

REFERENCES

Abidi N, Motamed N. (2011). School of Allied Health and Nurs-

ing students’ and teachers on the Bushehr University of Medi-

cal Sciences and Clinical Education. Strides Dev Med Educ;

8(1): 88-93. (Persian)

H. Karimi Moonaghi et al.

550 PERCEIVED CHALLENGES BY THE IRANIAN BACCALAUREATE SURGICAL TECHNOLOGY STUDENTS BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS

Andrews GJ, Brodie DA, Andrews JP, Hillan E, Thomas BG,

Wong J, Rixon L. (2006). Professional roles and communica-

tions in clinical placements: a qualitative study of nursing stu-

dents’ perceptions and some models for practice. International

Journal Nurs Study; 43 (7):861-874.

Bahrami, T. Sadat, L. E. Mahmoudi. Golgini. E. (2014). Evalua-

tion of the clinical training of students’ views in the operating

room and anesthesia Alborz. University of medical scienes and

health .Journal of Alborz University of Medical Sciences. Vol-

ume 1, Number 3, summer 143-150, 139. [In Persian]

Bailey L. (2010). Strategies for decreasing patient anxiety in

the perioperative setting. AORN J; 92(4): 445-57

Burns, N; Grove, SK.(2007). Understanding nursing research,

building an evidence-based practice. 4th edition. St. Louis:

Saunders Elsevier.

Dehghani H, Dehghani K, Fallahzadeh H. (2005). The edu-

cational problems of clinical  eld training based on nursing

teachers and last year nursing student’s viewpoints. Iranian

Journal of Medical Education; 5(1):24-33. [Persian]

Deyoung S. (2009). Teaching strategies for nurse educators. 2th

Ed. New Jersey: Prentice Hall. P.222-223.

Silen-Lipponen, M; Tossavainen, K; Turunen, H; Smith, A.

(2004). Learning about teamwork in operating room clinical

placement. British Journal of Nursing; 13.5 (24); 244-253.

Farneya, F; Abbaszadeh. A; Borhanif, F. (2013). inhibiting fac-

tors associated patient care in the operating room: a qualita-

tive content analysis. Journal of Health Sciences Research; 2

(1): 90-7.

Ghorbanian N, Abdollahzadeh Mahlani F, Kazemi Haki B.

(2014). Effective Factors on Clinical Education Quality; Anes-

thesiology and Operating Room Students View. Bimonthly

Educe Strategy Med Sic; 6 (4):235-239. [In Persian]

Graneheim UH, Lundman B. (2004). Qualitative content analy-

sis in nursing research: concepts, procedures and measures to

achieve trustworthiness. Nurse Educ Today; 24(2): 105-12.

Hadizadeh F, Firoozi M, Shamaeyanrazavi N. (2005). Gonabad’s

nursing students’ views about clinical Education assessment.

Iranian Journal of Medical Education; 5(1):70-8. [Persian}

Heshmati, Nabavi1, F. Vanaki, Z., Mohammadi, E. (2012). A

Critical Review on Communication Paradigms Beteween Aca-

demic and Clinical Service Institutions in Nursing. Iranian

Journal of Medical Education: 11(6); 554-568

Heshmati-Nabavi F, Vanaki Z. (2010). Professional approach:

the key feature of effective clinical educator in Iran.

Islamic Republic of Iran Ministry of Health and Treatment and

Medical Education Supreme Council for Planning of Medi-

cal Sciences, Educational programs of Baccalaureate Degree

operating room, Pro le, program, curriculum and evaluation

method. Adopted by 35 Th session of the Higher Council for

Planning of Medical Sciences: 20 /12/2007.

Kenton, K. (2006). How to Teach and Evaluate Learners in the

Operating Room. Obstetric Gynecology Cling N Am; 33; 325–

332.

Khazaei, J, Zarouj, H.Abbasi A. (2014). Quali cation of Clini-

cal Education of operation room in Bachelor degree from the

perspective of students and educators in this  eld at the Uni-

versity of Medical Sciences, in Semnan Journal of Education

and Ethics in Nursing; Volume 3, Number 3, 39-46 [In Persian]

Khazaei, J, Zarouj, H.Abbasi A. (2014). Quali cation of Clini-

cal Education of operation room in Bachelor degree from the

perspective of students and educators in this  eld at the Uni-

versity of Medical Sciences, in Semnan Journal of Education

and Ethics in Nursing; Volume 3, Number 3, 39-46 [In Persian]

Laura, C; Skoczylas, E B; Littleton, Steven, L; Kanter and Gary

Sutkin. (2012). Teaching Techniques in the Operating Room:

The Importance of Perceptual Motor Teaching. Academic Med-

icine; 87(3).

Lingard, L; Reznick, R; Espin, S; More. (2002). Team Communi-

cations in the Operating Room: Talk Patterns, Sites of Tension,

and Implications for Novices. Academic Medicine; 77(3):232-

237.

Manninen E (1998) Changes in nursing students’ perceptions

of nursing as they progress through their education. J Adv

Nurs 27: 390-8

Mayring p. (2000). Qualitative Content Analysis. Forum: Qual-

itative Social research; 1(2): 25-30

Moussaoui, S. (2005). Professional problems from the perspec-

tive of employees working in operating rooms. Hamedan Uni-

versity of Medical Sciences Journal; 12(47)

O’Driscoll M, Allan H, Smith P. (2010). Still looking for leader-

ship–Who is responsible for student nurses’ learning in prac-

tice? Nurse Education Today; 30(3):212-7

Omidvar S, Bakouee F, Salmalian H. (2010). Clinical education

problems: the viewpoints of midwifery students in Babol Uni-

versity of Medical Sciences. Iranian Journal of Medical Educa-

tion; 5(2):15-. [Persian]

Operating room and anesthesia, Introduction of operation

room. Available from: URL; http:// www.mums.ac.ir/ornanesn/

fa/historyOR. Accessed: 27/5/2017

Riley R, Manias E (2002) Foucault could have been an operat-

ing room nurse. J Adv Nurs 39: 316-24 -15

Sadeghi A (2011). “A case study: the association between

organizational culture with management knowledge in

Hasheminezhad hospital – Tehran. Of cial Journal of the

organs of administration of the hospitals in Iran, Issue 2, sum-

mer. No.37:1-8

Tanner J, Timmons S (2000) backstage in the theatre. J Adv

Nurs 32: 975-80

Tazakori, Z. Mehri, S.Mobaraki, N.Dadash L. Ahmadi Y. Shokri,

F.Hamrang, L. (2016). Factors Affecting on Quality of Clini-

cal Education from Perspectives of Operating Room Students.

Journal of Health and Care; 17 (2): 128 -136. [In Persian]

Zeighami R Faseleh M Jahanmiri Sh Ghodsbin F. (2004). Nurs-

ing student’s viewpoint about problems of clinical teaching.

The Journal of Ghazvin University of Medical Science; 8(30):

51-5. [Persian]