NUR5223 Module 3 learning environment analysis example

Where the Fellow Stands in Room 6: The Operating Room as a Learning Environment, Read Through Situated Learning and Psychological Safety, With Five Changes

Student Name

American College of Education

NUR5223: Theoretical Foundations in Teaching and Learning

Module 3 Assignment

Instructor Name

May 23, 2028

The Environment and the Evidence

The perioperative fellowship described in the previous modules places eight experienced nurses in the hospital's 16 operating rooms, each paired with a preceptor for the day. The rooms are where most of their learning happens, and where it most often stalls. To understand why, the author drew on three sources: the weekly reflective journals the fellows write, observations the author made during twelve cases, and a short anonymous questionnaire completed by the fellows at week six.

Several patterns emerged. Fellows were assigned to a different preceptor on most days, so each morning began with a new person who did not know what the fellow could already do. During busy cases, fellows often stood against the wall by the door, out of the way, watching tasks they could not see clearly. Three fellows described being spoken to sharply by a surgeon for moving too slowly, and two said a preceptor had taken over a task without explanation when the room was running late. Six of eight wrote in their journals that they had held back a question at least once because the moment felt wrong. On the other hand, fellows consistently described two preceptors whose rooms felt different: they explained what they were doing as they did it, asked the fellow to take the next step and introduced the fellow to the surgical team at the start of the case.

Two Theories

Lave and Wenger (1991) proposed that learning is situated in communities of practice and that newcomers learn through legitimate peripheral participation: they begin at the edge of the community's work, doing real but limited tasks, and move toward full participation as their competence grows. Learning, in this view, is not only acquiring knowledge but becoming a member of the community, and it depends on access. Newcomers who are kept from meaningful tasks, or who cannot see and hear the work of experienced members, cannot move inward.

Edmondson (1999) used the term team psychological safety for a belief, held in common by a team's members, that they will not be punished or humiliated for speaking up with a question, an error or a concern. Where that belief was strong, members asked for input and talked openly about errors more often, and those teams performed better. For learners, psychological safety determines whether they will ask the question that exposes what they do not know, which is the question most likely to lead to learning.

The Environment Through the Theories

Physical environment. The operating room offers little room for a learner. A fellow standing by the door is peripheral in Lave and Wenger's sense but not legitimately so: the position gives no access to the work. Legitimate peripheral participation requires tasks that are small but real, such as setting up the suction, receiving an item from the sterile field or documenting a count, and a position from which the learner can see and hear the experienced circulator's decisions.

Social environment. The operating room has a steep hierarchy, and disruptive behavior is common there. A review of disruptive behavior in the perioperative setting reported that up to 98% of clinicians had witnessed it in the previous year and that it undermines teamwork and communication (Villafranca et al., 2017). Learners are especially exposed: in a survey of 215 nursing students in one hospital's operating rooms, 56.7% had experienced incivility, most often a raised voice (Shen et al., 2020). Sharp words from a surgeon teach a fellow to stay silent, which is the opposite of what the circulating role requires. An environment that punishes questions produces circulators who do not speak up, which is a patient safety problem that begins as a teaching problem.

Organizational environment. Rooms are measured on turnover time and on-time starts, and when a room runs late, teaching is the first thing dropped. The preceptor who took over a task without explanation was responding rationally to the organization's measures. Changing assignment every day prevents any preceptor from building the knowledge of a fellow's abilities that is needed to move the fellow inward at the right pace.

Instructional environment. The two preceptors fellows praised were doing what situated learning describes: making their thinking visible, giving the fellow a real part in the work and bringing the fellow into the team. They were also building psychological safety, by signaling that questions were expected. Neither had been trained to precept; their skill was personal rather than designed into the fellowship.

Five Changes

First, consistent preceptors. Each fellow will work with one primary and one secondary preceptor for the first three months, so that the preceptor knows what the fellow can do and can extend responsibility deliberately. Second, a participation ladder. The fellowship will define a sequence of tasks from the periphery to the center of the circulating role, beginning with room setup and documentation and ending with running the count and leading the time-out, and each fellow's position on the ladder will be visible on a card the preceptor updates. Third, a pre-case introduction. The preceptor will introduce the fellow by name and role at the team briefing, and will say which tasks the fellow is performing, which signals to the whole team that the fellow is a legitimate participant and that questions are expected. Fourth, protected teaching rooms. On two days a week, one room on each service line will be scheduled with a small buffer so that the preceptor can teach without being pushed to take over. Fifth, preceptor development. All preceptors will complete a four-hour workshop on making thinking visible, giving feedback and responding when a fellow is treated with incivility, including how to speak to a surgeon about it afterward.

The changes are sequenced so that the least costly come first. Consistent preceptor assignment and the pre-case introduction require only scheduling and habit, and will start with the next cohort's first week. The participation ladder needs a month of work with experienced circulators to agree on the order of tasks, and will be piloted on two service lines. The preceptor workshop will run twice before the next cohort starts. Protected teaching rooms require the agreement of the surgical services director and the chief of surgery, because they affect the schedule, and will be proposed with the data from this analysis, including the fellows' journal entries, which make the problem vivid in a way that turnover figures do not.

Judging the Effect

The changes will be judged by the fellows' responses to a short psychological safety questionnaire at weeks six and sixteen, compared with this cohort; the number of journal entries describing a withheld question; the pace at which fellows move up the participation ladder; and preceptors' ratings of fellows' independence at six months. The protected rooms will also be checked against turnover times, since a change that damages the department's performance will not last. The author expects the pre-case introduction to be the cheapest change and among the most powerful, because it costs ten seconds and changes how every person in the room sees the learner.

References

Edmondson, A. (1999). Psychological safety and learning behavior in work teams. Administrative Science Quarterly, 44(2), 350-383. https://doi.org/10.2307/2666999

Lave, J., & Wenger, E. (1991). Situated learning: Legitimate peripheral participation. Cambridge University Press.

Shen, H., Wang, H., Yan, L., Liu, W., Zhang, J., Zhou, F., Kong, S., & Deng, L. (2020). Incivility in nursing practice education in the operating room. Nurse Education Today, 88, Article 104366. https://doi.org/10.1016/j.nedt.2020.104366

Villafranca, A., Hamlin, C., Enns, S., & Jacobsohn, E. (2017). Disruptive behaviour in the perioperative setting: A contemporary review. Canadian Journal of Anesthesia, 64(2), 128-140. https://doi.org/10.1007/s12630-016-0784-x