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Reflection on Learning in the OperatingTheatrePatricia M.A. Lyon a & Angela Brew ba Department of Surgery, Faculty of Medicine, A27, University ofSydney, NSW, 2006, Australia E-mail:b Institute for Teaching and Learning, University of Sydney, CarslawF07, NSW, 2006, Australia E-mail:Published online: 18 Aug 2010.

To cite this article: Patricia M.A. Lyon & Angela Brew (2003) Reflection on Learning in the OperatingTheatre, Reflective Practice: International and Multidisciplinary Perspectives, 4:1, 53-66, DOI:10.1080/1462394032000053495

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Reflective Practice, Vol. 4, No. 1, 2003

Reflection on Learning in the OperatingTheatrePATRICIA M.A. LYONDepartment of Surgery, Faculty of Medicine, A27, University of Sydney, NSW 2006,Australia; e-mail:plyon@surgery.usyd.edu.au

ANGELA BREWInstitute for Teaching and Learning, Carslaw F07, University of Sydney, NSW 2006,Australia; e-mail: A.Brew@itl.usyd.edu.au

ABSTRACT Medical students spend time during their course attending the operatingtheatre. This forms part of their surgical studies. This paper reports on the first completedresearch project to empirically examine students’ experiences of teaching and learning in thissetting. A multi-method interpretive case study strategy focused on students’ experiences inone Australian university was used. This included in-depth interviews with students andsurgeons, observations in the operating theatre, group interviews and a survey withstudents.

The paper firstly describes the operating theatre as a complex and highly chargedworkplace and outlines the challenges for students’ learning. It then examines the strategiesstudents use to learn in this context. The paper argues that students who report getting themost out of their experiences successfully manage their learning in three domains: thephysical environment and the emotional impact of surgery as work; educational tasks andlearning objectives, and the social relations of working in the operating theatre. The paperhighlights the differences in how students reflect on their experiences to turn them intolearning. The models of learning from experience and of reflection in learning developed byBoud and colleagues (Boud Keogh & Walker, 1985; Boud & Walker, 1991) are used asframeworks for understanding students’ responses and for suggesting ways in which learningin professional contexts can be enhanced.

Introduction

In the clinical years of most medical programs in the United States, Europe andAustralia, medical students are rostered into surgical and medical clerkships, rota-tions or attachments, mainly in large teaching hospitals, where they ‘clerk’, assistand observe the team management of patients. Teaching and learning take place inlecture theatres, in seminar and tutorials rooms, and in experienced-based learningenvironments at the bedside in the wards, in clinics and in operating theatres. As

ISSN 1462-3943 print; 1470-1103 online/03/010053-14 2003 Taylor & Francis LtdDOI: 10.1080/1462394032000053495

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part of their general medical training, students learn about the management and careof the surgical patient. They are taught to take a history, to conduct a physicalexamination and to make a diagnosis. They learn about investigations, the principlesof management (operative or other), and the principles of postoperative care. Theyattend the operating theatre with their patient to observe the procedure when anoperation is the chosen management option. They are not expected to have athorough understanding of the technical details nor to develop technical skills in theoperative procedure itself.

The operating theatre offers an enormous potential for students to see livepathology, to increase their understanding of anatomy as it relates to the processesof disease, to observe real clinical problems and their surgical treatment, to begin toappreciate what surgery means to patients both physically and emotionally, toobserve surgical decision making, and to gain important insights into the work of thesurgeon. However, the extent to which students are able learn from their experiencesin the operating theatre depends on their capacity to learn from what actually occurswhen they are there. This paper argues that students’ capacity to reflect on theirexperiences and act on the basis of that reflection crucially affects their learning. Itsuggests that students’ learning in this and similar professional contexts can beenhanced by extending their repertoire of strategies for reflection and proposes waysto do this.

Assumptions made about the teachers’ capacity to change the learning milieu(made in the general literature on what makes for effective teaching and learning inhigher education—see for example, Ramsden, 1992) are not applicable in thecontext of teaching and learning in the operating theatre. Strategies to improveteaching and learning in theatres need to take account of the messy and unpredict-able reality of the operating theatre as a workplace where patients’ needs and not theneeds of medical students are the focus of attention. Students become peripheralparticipants in what Lave & Wenger (1991) describe as a community of practice.Students need, in this context, to be able to make the most of their experiences.Managing their learning in the operating theatre is more akin to strategies used inworkplace learning than in other contexts of teaching and learning in highereducation.

Surgical educators have written extensively about the characteristics of the surgi-cal clerkship such as curriculum content, assessment, objectives, and evaluation, yetthe uniqueness of the operating theatre as a clinical environment, which is part of thestudents’ experience of the surgical clerkship, has been relatively neglected in theliterature. In terms of reported studies we know the least about teaching in theoperating theatre (Dunnington, et al., 1993, p. 523). What literature does exist islargely normative in character and based upon the authors’ experiences as practisingsurgeons. The few published empirical studies have focused on identifying appropri-ate content and effective behaviours for teaching in the operating theatre (Dunning-ton et al., 1993; Hauge, et al., 2001; Lockwood et al., 1986; Scallon et al., 1992).

This paper, in contrast, draws on the first empirical study to examine howstudents learn in the operating theatre and how that learning might be improved.The research used both quantitative and qualitative methods to examine students’experiences of teaching and learning in the operating theatre in the Department of

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Surgery at an Australian university. It included two group interviews with sevenstudents, observations in the operating theatres on 12 separate occasions, 15in-depth interviews with students, ten in-depth interviews with surgeons, and asurvey of one cohort of 197 out of 237 students (i.e. a response rate of 83%). Typedtranscripts of the audio-taped interviews together with field notes from the observa-tions provided 39 pieces of text for qualitative analysis. This was done using aniterative grounded theory approach (Strauss & Corbin, 1990). (For further infor-mation concerning the methods of the study see Lyon, 2001.)

The paper firstly identifies the challenges for students’ learning and the strategiesstudents use to make the most of their learning opportunities which the study hashighlighted. The model of learning from experience developed by Boud and Walker(1991) is then used as a framework to understand the reflective processes studentsare engaged in, and, given the constraints in the setting (e.g. infection controlprotocols, patient care, risk associated with surgical procedures, etc.), how thislearning might be enhanced by extending the students’ skills in reflection. Finally,some examples of interventions to better prepare students for learning in this settingand to enhance students’ learning experiences are presented and some implicationsfor teaching and learning in higher education in general are drawn.

Managing Learning in Three Domains

From the iterative analysis it was possible to identify a key core category in Straussand Corbin’s (1990, p. 121) terms which illuminates what the data were essentiallyabout; namely the way students manage their learning in the professional workplacesetting of the operating theatre. This core category appeared to have three relateddomains (see Figure 1). While recognising that this data analysis process is essen-tially interpretive, the identification of these three domains and the core category hasproved useful in highlighting the challenges faced by students.

The first domain: Managing the demands of the working environment

The operating theatre is a noisy, busy and sometimes tense working environment. Itcan be a confronting, unpredictable, and disorienting place for a medical student tolearn and a challenging place for a surgeon to teach. Students have to learn tonegotiate the physical environment of the operating theatre as a workplace, to learnthe protocols and to familiarise themselves with the unfamiliar environment. Stu-dents can find it intimidating. This is in part, because of the fear of doing somethingwrong and adversely affecting the patient outcome. In part, it is the fear of appearingfoolish:

You can make a fool of yourself if you make a bold statement and youreally didn’t have a clue … So, you’ll say, ‘Would that be the …?,’ this iswhat I was saying before, you’ve got to be fairly sure you’re right if you’regoing to ask them to explain the anatomy to you because you don’t wantto be made a fool of … You can make a fool of yourself if you don’t knowthe anatomy of the operation. You can make a fool of yourself if you don’t

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FIG. 1. Managing learning across three domains.

know the etiquette of green, and you don’t know the etiquette of sterilefields. Initially when you haven’t scrubbed much you’re reticent to ask toscrub just simply because it is a ritual you’re unfamiliar with and every-body’s going to be watching you and you don’t want to look clumsy. That’ssomething that you’ve got to overcome, … and you just keep on doing itand doing it and OK you might have to make a fool of yourself, ten, twentytimes maybe, you know, before it’s absolutely down pat. (Student 5)

It is also in part, because of the emotional impact of the surgical procedures and thetensions that may arise amongst the various teams in the theatre when complicationsarise:

… there’s a lot of tension. If there’s some prima donna in there, they(students) may well walk in when, you know, the surgeon’s upset, andabusing, and all this sort of thing, and, you know, to an idealistic medicalstudent who’s young and smart … they may go in there and think this isa sort of medieval—they might walk in at the wrong time and see someone(surgeon) screaming, performing, and they think, ‘… I didn’t go intomedicine to see this sort of behaviour’. But the fact is, that person is

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probably under a lot of tension, they’re (students) just seeing the kind ofstresses placed on individuals … (Surgeon 10)

The extent to which students are able to manage these challenges is going tocrucially affect what they learn from their experiences.

The second domain: Managing the educational tasks

Students who reported having a useful learning experience had a clear sense of thelearning objectives and of the relevance of attendance in theatres whilst attending tothe formal assessment requirements set by the academic institution of the university.

Whilst, at the time of the study (1996–1999), the learning objectives were notclearly spelt out in any of the curricular documents, the majority of students couldsee the relevance of learning from the operating theatre. Statistical analysis of thesurvey data indicated a highly significant correlation (P � 0.01) between students’perceptions of the importance of understanding what happens during operativeprocedures for learning in surgery, and their perception of the usefulness for learningof the time they spent in theatre. Students who had no intention of pursuing asurgical career could nevertheless see value in attending theatres. Those planning tobe general practitioners or planning a career in medicine could see the value inlearning from theatre as preparation for internship, and for their later professionalpractice, when they will need to explain surgical procedures to patients:

If someone was to ask you what’s going to be involved in an appendicec-tomy you could sort of explain what was going to happen to them beforethey get into theatres, you could explain to them what [was going to]happen during the theatre and what’s going to happen to them aftertheatre, for example whether they’ll be going to the Intensive Care Unitetc…. if I was to become a GP or an intern later it’s going to be a vital skillfor me, or knowledge for me. Because I guess lots of patients will be talkingto you more, because you’re mostly in the wards if you’re doing surgery asan intern and if they have any questions they can ask you and you canexplain all that to them, so that’s most helpful. (Student 14)

At the time of the study, medical students were required, as part of the surgicalattachments, to complete various assessments including case histories based onpatients they had clerked. (With the introduction of the new medical programstudents continue to attend the operating theatre as part of their surgical educationbut are no longer required to submit written case histories.) Students were cynicalabout these assessments which counted for a small percentage of the total marks inthe overall assessment scheme for final year. Learning from the operating theatrerequires an investment in time: the time it takes to get changed and find the righttheatre; the time it takes waiting for one’s patient to arrive at the theatre suite; andthe time waiting between operations. Students were conscious of using their learningtime efficiently given their perception of what was needed to pass the final examina-tions:

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Students, you know, during six years, start to evaluate their time and youknow they put a cost to it and they say, ‘Well, I may spend four or fivehours in theatre watching an operation, now what am I going to get fromthat? … my time is probably better served either going studying or seeingpatients.’ And a lot of people would prefer to do that. [It’s] not that they’renot interested but simply because at the end of the year comes the examsand the way the exams are structured it’s much more beneficial to do this.(Group interview 1)

This suggests that it is up to the student to define their own learning goals in relationto what they want to learn from their experiences in the operating theatre, but in theunpredictability of their experiences, they need to be able make the most of theirexperiences whether positive or negative.

The third domain: Managing learning and the social relations of work in the operatingtheatre

A range of learning behaviours was observed in the operating theatre. Some medicalstudents appeared to be more confident in initiating interaction with the surgeon,asking questions, asking to scrub in and to assist if it seemed appropriate. Beingscrubbed up enables the medical student to take a place at the table, along with thesurgical trainees, close to the leading surgeon. Some students were more comfort-able than others in leaving the theatre if its learning potential was limited. Somewere more sensitive to having their ‘toes trodden on’, whilst others were prepared totake risks with their learning, to ‘cop a bit to learn a bit’. A few were more familiarwith the workplace environment of the operating theatre having been trained asnurses prior to beginning their medical degree, whilst others found it more unfam-iliar, intimidating and inhibiting. Students who report successful learning experi-ences from the operating theatre had a measure of social competence to negotiate anactive role to play in the surgical team. They had learned to negotiate the socialrelations of work in the operating theatre, to find a legitimate role to play in orderto participate in the community of practice (Wenger, 1998) constituted by theoperating theatre and its personnel.

Reflection and Learning in the Context of Students’ Experiences in the

Operating Theatre

Boud and Walker (1991, p. 19) argue that in any learning situation there is alwaysreflective activity ‘in which what is perceived is processed by learners and becomesthe basis of new knowledge and further action’. This reflection process, which theycall reflection-in-action is constantly active within the learner’s experience and iscentral to understanding experience-based learning. Essential to the reflective pro-cess they suggest are two important aspects of the learning experience, noticing andintervening. Boud and Walker argue that ‘if these can be enhanced, then the wholeprocess is enriched’ (Boud & Walker, 1991, p. 23). We have found these concepts

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particularly illuminating with regard to student learning in the professional workplacesetting of the operating theatre.

In one sense noticing is a central objective of the student’s experience of attendingin the theatre with their patient, where noticing is defined narrowly to refer toobservation of the surgical procedure and the surgical management of the patient.The operating theatre affords all students the opportunity to learn from observing theprocedures, more or less, depending on their view of the operating field. Somestudents exploit the opportunities further by influencing their experience in the milieuto maximise their learning. The starting point for these students in learning from theexperience is to notice not only the procedure but what is happening in and aroundthem. This is the broader sense of the term noticing.

Noticing is … active and seeking: it involves a continuing effort to be awareof what is happening in ourselves and in the learning event … It is directedto both the exterior and interior worlds. On the interior, it involves takingnote of our own thoughts and feelings … On the exterior, it requiresattending to the nature of the event and its elements: the forms of interactionbetween participants, the use of language, cultural patterns, documents andobjects used, declared intentions, the continuing change within the experi-ence, the presuppositions on which the action of participants are based, theemotional climate of the event and a variety of other things. Noticing actsto feed information from the learning milieu into the continuing reflectiveprocess, which is integral to the experience, and enables learners to enterinto further reflective interaction with it. (Boud & Walker, 1991, p. 23)

Students who actively seek out this information in the operating theatre notice theresponsiveness of the surgical team; the attitude of the nursing staff; the emotionalclimate; the number of other learners and the opportunities for a place at the table;the busyness of the theatre; and the norms of the team with respect to rules of dress,etiquette and infection control. They reflect on these cues, sizing up the learningpotential of any particular theatre and make choices about their learning behaviour.

Students who seek to make the most of the potential of the operating theatre usea number of strategies or interventions (Boud & Walker, 1990) to manage theirlearning. These may include assisting with the patient preparation; asking to scrubin and assist with the operation; asking intelligent questions about the case and theradiology; behaving professionally and presenting oneself as a legitimate learnerworthy of a place in theatres.

Motivated students monitor their own learning in the situation and intervene tomaximise the learning opportunities. These interventions include: selecting theatreswhere they can observe common procedures; asking for recommendations aboutuseful theatres to visit from other students; trying out several theatres within a unitand choosing one with a ‘student-friendly’ surgeon; noticing and reflecting on howa surgeon treats other more senior surgical trainees; asking other theatre staff aboutopportunities for learning in particular theatres, helping to prepare the patient andthen, as we have seen, asking to scrub in, actively promoting themselves as legitimatelearners in the training queue.

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Students at interview spoke about the variation in the extent to which studentswould intervene and take the initiative to extend their knowledge, relating thedifferences to their own or other students’ previous experiences as learners:

… you need to be a natural born student and you need to promote yourpresence as a student and their role as a teacher. This isn’t something I’vedone consciously, I just think I’m an extroverted person who’s not afraidof authority and all that sort of stuff, so I think it’s easier for me. I thinkit’s a lot harder for students who revere their superiors more. (Student 5)

[Observation note] The student says that the older students have moreconfidence in talking to the surgeons. She says they can ask if they canscrub or get closer to see and ask questions without being intimidated, sothey get more out of going to theatre. She says it could be ‘an intimidatingenvironment for shy 23 year-olds’. (Observation 6)

It’s much more, the onus is on the student, and for some students whosepersonalities don’t lend themselves to really presenting themselves [aslegitimate learners], it’s very difficult. (Group interview 2)

Interventions will always be affected by the milieu itself, for the milieu is dynamic.This is particularly true, Boud & Walker argue, when people are part of the learningmilieu:

Relationships with coworkers will affect how a person intervenes. Interven-tion to test or challenge the presuppositions of others can so affect themthat the situation can change significantly, and an initial approach can leadto a series of actions which transform the situation and may create apotentially more creative context for learning. This will affect how learnersintervene in the situation. A particular action already performed, whichbrought about a particular effect, may not achieve the same effect in thechanged situation. (Boud & Walker, 1991, p. 28)

This is illustrated by a quotation from a student, recorded as we stood talkingtogether in the corridor, after he had had a particularly useful interaction with asurgeon, where had been very actively involved in the theatre session, interveningusefully to create a worthwhile learning experience. Here he is reflecting on hisexperiences in theatres the day before:

[Observation note] Student A talked about yesterday’s experience withanother surgeon—not so useful he says. He says he tried asking the oddquestion but the surgeon didn’t seem very responsive, but A says it waspartly his fault because he didn’t ask many questions because the surgeondidn’t seem very approachable—‘You have to show interest to get them toteach—you have to be pro-active, but yesterday it wasn’t so easy to askquestions because the surgeon wasn’t very approachable. It was partly hisfault and partly mine’. (Observation 12)

Boud & Walker argue that interventions are influenced by a number of factors:

… by the reflective process, by the learner’s foundation of experience, byintent, by the skill of the learners and by the learning milieu itself. The

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reflective process which runs through the experience is a very significantinfluence on the actions of learners within the situation. Learners arealways actively working with the data of the situation and this influencesthe way in which they act. Some actions may be simple responses to thesituation. Others may arise out of a combination of the data and theprevious intents of learners. Even where some actions have been previouslydecided, or are being influenced by factors prior to the experience, theirtiming and the way they are actually performed will be influenced by thelearner’s reflection within the situation. (Boud & Walker, 1991, p. 27)

This reflective process in action is illustrated here with a comment from one of thestudents:

[whether you ask to scrub in] depends on why you are there. Sometimesthere’s a particular operation that’s important … that you really want tohave participation in it and actually find out … Then the need to actually,to get to scrub up becomes the overriding factor and you have to gothrough it, you have to ask [to scrub], even though you’re not invited youhave at least to try. Whereas sometimes, if you’re just there for interest’ssake then you take the ‘wait and see’ approach and see if you’re invited.You can say to yourself, ‘Oh well, not invited this time, hopefully maybenext time’. Sometimes you just say, ‘OK, well I’m getting really bad vibesfrom this surgeon so I’ll just stay here and be quiet’. (Student 15)

One of the most important ways to enhance learning from experience, Boud andcolleagues argue, involves reflection after the experience (Boud et al., 1985, pp. 26–27)which includes three elements:

• returning to the experience—recollecting the salient events, replaying the experiencein the mind of the learner or recounting it to others

• attending to feelings—focusing on positive feelings and removing obstructing feel-ings

• re-evaluating experience—re-examining experience in the light of the learner’sintent

There are currently no formal opportunities for students in the clinical years of theprogram to reflect after the experience of attending theatres. Interestingly, thestudent interviews conducted as part of the study did themselves involve students inthe first of the two elements of the reflective process identified above. Both the groupinterviews and the individual interviews began with the invitation to the students totell the interviewer about their experiences of teaching and learning in the operatingtheatres where they had attended with their patients. The students recounted howthey had stumbled across the unfamiliar culture of the operating theatre and learnedto cope in it; of times when they had learnt so much and other times when they feltthey had wasted their time; they talked about their interactions with the various teamplayers in theatres and about the responses to them which prompted them to act asthey did. In the group interviews students were able to learn about the different waysin which different students handled difficult situations; about what different studentsvalued in their experiences; and about the different perspectives students develop inreflecting on their experiences.

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The students talked about times in theatres when they had been inspired andencouraged, or intimidated and embarrassed. They described what they regarded asworthwhile about an experience recounting times when they felt good about them-selves, their teachers and their learning. In the group interviews it was common forstudents to discharge negative emotions when, for example, they recounted howthey had made a fool of themselves in theatre, by laughing together and sharingsimilar experiences.

Promoting Learning through Reflection

Given the situation of complexity of the operating theatre the question to now beaddressed is how learning in busy and emotionally charged workplaces such asoperating theatres can be enhanced. In the final part of the paper we look at theapplication of Boud and Walker’s framework for learning in the operating theatre.Boud and Walker suggest that there are three key areas that educators need toconsider in designing any educational activities: preparation before the event, theexperiences in which students engage, and subsequent reflection on the event (Boud& Walker, 1991). In this section, we discuss attempts to enhance students’ reflectionin these three areas which have been tried, planned and suggested at the universitywhere the study was undertaken.

Preparation for the event

With respect to preparation before the event the focus is on preparing the studentfor what the event has to offer which includes equipping them with devices to assistthem with their own reflection-in-action, i.e. devices to help them to notice what willbe occurring in the event, what situations they are likely to encounter, appropriatemodes of behaviour, what opportunities are likely to be found and in particular howto intervene usefully to make the most of the opportunities.

With this focus the Department of Surgery at this university has introduced threeinitiatives to help medical students to prepare for theatres: a session in the hospitalorientation program designed to alert students to the complexity of the workplace intheatres, to point out the relevance and potential of learning from the operatingtheatre and to show how previous students have intervened to use the opportunities,drawing on data collected for the research reported here; a half-day interactiveteaching session conducted in the theatre suite which includes handwashing, gown-ing and gloving, theatre protocols, and an overview of the steps typically involved inan operation; and a new section of text in the student handbook outlining, forexample, the learning objectives, and a list of ‘must see’ operations.

Reflection-in-action

With respect to the event itself, i.e. attendance at the operating theatre, the focus ison helping students in theatre to engage with the learning experience, to notice andto intervene to promote their own learning. Sometimes in theatre a senior registrarwould be conducting the operation under the supervision of the senior surgeon who,

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when the operation was running smoothly and according to plan, would be free todirect students to notice things that might have otherwise have gone unnoticed, toassist the interaction between the learners and the learning milieu. In one particularinterview a student recalled an occasion where the surgeon, alert to the learners’feelings, changed the learning milieu from within by limiting the aggression ofanother member of the team, assisting the learner to resolve negative emotionswhich inhibit noticing.

So the surgical and nursing staff have a role to play and the need for training forthem to help students make the most of their experiences is clearly indicated. A staffdevelopment workshop is planned where the findings from the empirical studyreported here will be presented with activities designed to help teachers understandthe students’ perspectives on attending theatres and to prompt them to devise waysof helping students to engage more fully with the learning experience in theatres.

The model of learning from experience is proving useful for teachers in thinkingabout how to prepare students for their experiences in the operating theatre. Interms of students, the student handbook, mentioned earlier, includes one interven-tion to assist students to monitor and reflect on their learning in action. It includesa template which students can take with them to theatres to assist them in monitor-ing their own learning to help them focus their attentions and to engage them in thelearning milieu.

An additional way to intervene to enhance students’ reflection in action is todevelop in them an understanding of the model itself. This can be a useful way forthem to extend their repertoire of responses when they are in theatre. So teachingthe model of reflection to students is a suggested way of highlighting to them theimportance of reflection as a way of helping them to manage their learning moreeffectively. Students who are aware of Boud and colleagues’ models of reflection andlearning from experience, and can apply them to their own practice, will be able toenhance their ability to manage their learning in complex settings and perhaps moregenerally.

Reflection after the experience

Reflection after the experience is one of the most important ways to help studentsto process their experiences and to extract, consciously, learning outcomes fromthem. Three elements have been identified as helpful: returning to the experience,attending to feelings, and re-evaluation (Boud et al., 1985). Whilst the individuallearner can work through these stages alone, trained facilitators bring a range oftechniques to help learners deal with challenging situations. It did seem that themedical students in the study reported here had given some thought to theirexperiences, in respect of the first two elements, prior to attending the interview,maybe in preparation, and some said they had talked through their experiences withtheir peers.

Whilst informal discussion with peers may be the preferred mode of reflection forsome students, more formal opportunities during the course of their clinical attach-ments to reflect on their experiences with a trained facilitator may enhance learning

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by providing the opportunity for all students to extend reflection to a new level ofre-evaluation.

On the basis of the findings of this study, what is envisaged is a workshopinvolving students in returning to experiences they have had in theatres. It has beenrecommended that a trained facilitator should work with students utilising theirpositive experiences and providing them with the impetus to persist in what mightbe very challenging situations, helping them to see events more sharply, providingthe basis for new affective learning (Boud et al., 1985, p. 29). The facilitator wouldassist students to deal with negative experiences which distract from further learningby helping them to express these feelings and then by discharging or transformingthe feelings. Role plays using scenarios developed by the students would focus onlearning in the affective and meta-cognitive domains. Boud and colleagues arguethat some of the benefits of reflection may be lost if they are not linked to action.One aim of such a workshop would be to help students make a commitment of somekind on the basis or his or her learning, in preparation for new experiences.

Outcomes expected from the workshop would be a positive attitude towardslearning in the operating theatre, greater clarity in understanding the experience,greater insight into how they learn, greater confidence or assertiveness or a greaterwillingness to try to intervene in a difficult theatre session, to turn their learningaround. At the very least, students would have the opportunity to share with theirpeers their personal experiences and to acknowledge as a group the complexity oflearning in the highly charged environment of the operating theatre. At best,teachers would discuss the whole model of reflection with students thus providingthem with a tool they can use in their professional practice more generally.

Conclusion

The operating theatre presents limited opportunities to change the learning milieuto suit a desire for effective student learning. In this respect it is unlike conventionallearning situations such as lectures, tutorials and the like, where the teacher hascontrol over the learning environment and can intervene to change it. It is suchcontexts which have tended to be the focus of attention in the higher educationteaching and learning literature (see for example, Ramsden, 1992; Prosser &Trigwell, 1999). The operating theatre is more like work-based learning situationswhere it is too dangerous for students to intervene in the actual tasks beingperformed (e.g. learning to operate a nuclear power station, learning to manage achemical plant). In contexts such as these, the nature of the learning is frequentlycomplex, problematic and multidimensional involving affective, theoretical, psycho-logical and practical skills. Such learning cannot be easily specified through a set ofclearly defined learning objectives in advance, but needs to be negotiated andattended to by the student in the act of experiencing the situation. So the way thestudent manages their own learning is crucial. In this paper we have drawn attentionto the role of reflection in the process of learning from experience using Boud andcolleagues’ (1985) model of reflection and Boud and Walker’s (1990 & 1991) modelof learning from experience.

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Boud and colleagues have argued that in the reflective process, students areengaged in a continuing cycle of noticing, reflecting, intervening, noticing andreflecting. Their model of reflection has been used here to understand the processof managing learning if students’ experiences are to result in effective learning.Medical students who report getting the most out of their time in the operatingtheatre engage in a reflective process, successfully managing their learning in threedomains. They ‘size-up’ the learning milieu noticing the attitude of the staff, theemotional climate, the opportunities for a place at the operating table, and they usevarious strategies or interventions to maximise the learning outcomes. In all of this,students process the data they receive using it to inform their learning behaviour.Motivated students adopt an active approach to their learning. They monitor theirlearning, intervening in the milieu when it makes sense to them to do so, becomingfully engaged with it, extending their learning by creating new and useful integratedexperiences.

In the study reported here, Boud and colleagues’ models of reflection and learningfrom experience have not only been found useful for analysing students’ behaviour,they have also proved useful for teachers when thinking about how to improve studentlearning in this context. In this paper we have demonstrated how the cycle of noticing,reflecting, intervening, noticing and reflecting in which students are engaged can beextended by providing students with formal opportunities to actively prepare for theexperience and to engage in reflection after the experience. We have suggested thatteachers can prepare and debrief students in relation to their learning in the operatingtheatre on the basis of these models, but importantly can develop students’ abilityas reflective practitioners more widely by drawing their attention to the model itself.

It has long been recognised that if students are to become competent professionals,their ability to engage in critical reflective practice is crucial (see for example Schon,1987). The operating theatre presents both teachers and students with an importantopportunity to develop and practice this within the medical education curriculum.In the complex professional world in which students will work when they leaveuniversity, they will have to take responsibility for managing their own learning withinprofessional practice. Thus the models of learning discussed in this paper are alignedmore with skills for lifelong learning that students will need later in professionalpractice, than the learning that takes place in the artificial learning situations oflecture hall or seminar room. This suggests, paradoxically, that learning opportunitiesin higher education should perhaps become more like learning in the operatingtheatre, not less. At the very least it suggests that more attention should be paid inresearch on teaching and learning in higher education to the contexts for learning andhow students can take responsibility to enhance their learning through whateverexperiences they are presented with.

Acknowledgement

The authors wish to thank Johnson & Johnson Medical Pty Ltd, Australia, forgenerous funding to support the establishment of the Surgery Education Centre atthe University of Sydney, thus making this research possible.

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