The Count That Did Not Close: A Three-Hour Session on Surgical Counts and Missing Items for Perioperative Fellows, With Every Activity Tied to Kolb, Bandura or Cognitive Load Theory
Student Name
American College of Education
NUR5223: Theoretical Foundations in Teaching and Learning
Module 5 Assignment
Instructor Name
June 6, 2028
Why This Session
Leading surgical counts is the task at the top of the participation ladder described in Module 3, and it is where the fellows' learning matters most for patient safety. Retained surgical items are rare but serious. In a case-control study of 54 patients with 61 retained sponges and instruments, 69% needed another operation and one died; emergency surgery increased the risk nearly ninefold, an unplanned change in the operation about fourfold, and each unit of body mass index by about a tenth (Gawande et al., 2003). Those are exactly the conditions in which a count is hardest to perform: a rushed case, a changing plan and a large patient. The fellows have performed counts under supervision since week three, but none has yet managed a count that did not reconcile, and two described in their journals freezing briefly when a scrub person said a sponge was missing. This session prepares them for that moment.
The learners are the eight fellows at week ten of the perioperative fellowship. They know the count procedure and can perform routine counts accurately. What they have not yet learned is the response when the count is wrong: how to stop the closure, direct a search, escalate, use imaging and document, while managing a surgeon who may want to keep going.
Objectives
By the end of the session, fellows will be able to: state the conditions that raise the risk of a retained item and adjust their counting practice when those conditions are present; carry out the hospital's procedure for a count discrepancy in the correct sequence, from announcing the discrepancy to documentation; use standard escalation language to stop the closure when a surgeon wishes to proceed; and, in a simulated case, lead a count that does not reconcile to a correct resolution within the time standard. Each objective describes observable performance, and the final one integrates the others in a realistic task.
The Session and Its Theory
Segment one, 20 minutes: a worked example. The session begins with a step-by-step walkthrough of the discrepancy procedure, using a single case shown in stages, with the reasoning at each step made explicit. Theory: cognitive load theory. Sweller et al. (2019) explain that working memory is sharply limited when learners face new, complex material, and that worked examples reduce unnecessary load by showing the solution path before learners must produce it. The discrepancy procedure has many steps under stress; seeing it worked through first reduces the load when fellows later perform it.
Segment two, 25 minutes: modeled escalation. An experienced circulator and the author role-play a discrepancy in which the surgeon, played by a volunteer surgeon, wants to close. The circulator uses the escalation language, and fellows watch for the specific words and actions. Theory: Bandura's social cognitive theory. Learning through observation of a model, and seeing a respected peer succeed in a difficult situation, is one of the sources of self-efficacy Bandura (1977) described, along with mastery experiences, verbal persuasion and managing physiological arousal. Fellows who have seen escalation done well are more likely to believe they can do it.
Segment three, 75 minutes: simulation. Each fellow leads a count in a simulated case on a manikin, with a scrub person and a surgeon played by staff. One sponge has been hidden in the simulated field. The case is emergent, the procedure changes midway, and the surgeon pushes to close. Theory: Kolb's experiential learning cycle. Kolb and Kolb (2005) describe learning as moving around a cycle: a learner has an experience, reflects on it, forms concepts that explain it and then tries those concepts out in a new situation. The simulation is the concrete experience, placing the fellow in the situation rather than describing it. The conditions, emergency and a changed plan, are those Gawande et al. identified as increasing risk, so the experience reproduces the conditions that make counts fail.
Segment four, 40 minutes: debrief and replay. After each simulation, the group debriefs in a structured way: what happened, what the fellow noticed and felt, what principles explain what went well and badly, and what the fellow will do differently. Each fellow then replays the critical minute, stopping the closure and directing the search, with a new variation. Theory: Kolb again. The debrief carries fellows through reflective observation and abstract conceptualization, and the replay provides active experimentation, completing the cycle. A simulation without a debrief is an experience; the debrief is what turns it into learning, and the replay is what tests whether it did.
Segment five, 20 minutes: personal plan. Each fellow writes the escalation phrase they will use and one condition that will make them perform an extra count in their next cases. Theory: self-efficacy again, through verbal commitment and a concrete plan for the next mastery experience.
Designing the Simulation for Realism and Safety
Two design decisions in the simulation deserve explanation. The first is realism. The scenario is written from a composite of the hospital's own count discrepancies over the past two years, reviewed with the perioperative quality nurse, so that the missing sponge is hidden where sponges are actually found, under the drape at the edge of the field, and the surgeon's objections use words the fellows will hear in practice: the count was right an hour ago, it is probably on the floor, we will get an X-ray afterward. The volunteer surgeon is briefed to push once firmly and then accept the fellow's escalation, because the aim is to rehearse successful escalation, not to defeat the learner. A fellow who freezes is prompted by the scrub person with a scripted question, what do you want me to do, which gives the fellow a way back into the task.
The second decision is psychological safety, which Module 3 identified as fragile in the operating room. The simulation begins with a short briefing that sets ground rules: mistakes are expected, what happens in the simulation stays in the debrief, and no one's performance will be reported to their manager. Fellows are told in advance that something will go wrong in the case, though not what, so that the stress is realistic without feeling like a trap. Fellows who watch rather than lead in a given round are given an observation task, tracking the time from the announcement of the discrepancy to the stopping of the closure, so that they learn from each other's performance and contribute to the debrief.
Assessment
Learning is assessed in three ways. During the simulation, the author rates each fellow on a checklist covering the discrepancy procedure's steps in sequence, the use of escalation language, time to stopping the closure and complete documentation, with a standard of all critical steps performed and the closure stopped within 60 seconds of the discrepancy being announced. Fellows who do not meet the standard repeat the scenario at the next session. A short scenario-based quiz on risk conditions and escalation is given at the end of the session and repeated at week sixteen. In practice, preceptors will record each fellow's first real count discrepancy and how it was managed, using the same checklist, and the fellowship will track whether fellows performed extra counts in cases with risk conditions.
The session will be evaluated by comparing checklist performance across the cohort, fellows' self-efficacy ratings for managing a discrepancy before and after the session, and the outcomes of real discrepancies managed by fellows in the following two months.
References
Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review, 84(2), 191-215. https://doi.org/10.1037/0033-295X.84.2.191
Gawande, A. A., Studdert, D. M., Orav, E. J., Brennan, T. A., & Zinner, M. J. (2003). Risk factors for retained instruments and sponges after surgery. New England Journal of Medicine, 348(3), 229-235. https://doi.org/10.1056/NEJMsa021721
Kolb, A. Y., & Kolb, D. A. (2005). Learning styles and learning spaces: Enhancing experiential learning in higher education. Academy of Management Learning & Education, 4(2), 193-212. https://doi.org/10.5465/amle.2005.17268566
Sweller, J., van Merriënboer, J. J. G., & Paas, F. (2019). Cognitive architecture and instructional design: 20 years later. Educational Psychology Review, 31(2), 261-292. https://doi.org/10.1007/s10648-019-09465-5
How this NUR 5223 Module 5 example is structured
NUR 5223 Module 5 commonly designs a teaching session with each activity tied to a named theory; your classroom's instructions decide the topic, length and template. This example states the learners and the content's importance, writes objectives, sets out the session in timed segments with the theory behind each, and specifies assessment, so a reader can see why every activity is there.
NUR5223 Module 5 questions, answered
What does NUR5223 Module 5 usually ask for?
NUR5223 Module 5 commonly asks you to design a teaching session in which each activity is linked to a named learning theory, with objectives, timing and assessment. Your classroom's instructions decide the topic and template.
Can I use more than one theory in a session design?
Yes, if each theory is used for the activity it best explains and you state the link explicitly. Using the same theory for everything is not required and often less convincing.
How detailed should the session plan be?
Detailed enough that another educator could run it: timed segments, what learners and teachers do in each, the materials needed and how learning will be assessed.
Write yours, or have the desk draft it
This paper is an original model document written by our desk, not a submitted student paper and not an official American College of Education document. Read it for the moves, then write your own to the instructions in your classroom. If you want one built to your exact prompt and rubric, the first custom sample is free and arrives in 24 to 48 hours.