Social Norms and Medical Students’ Engagement With Cadaveric Dissection: A Qualitative Study and Integrated Model of Cadaveric Engagement (IMCE Model)

Abstract

Background

Cadaveric dissection is vital in medical education, offering essential hands-on experience in human anatomy. With cadavers regarded as the “first teacher,” students confront the realities of death early in their training. All medical students are expected to participate actively in dissections. However, inconsistencies in attendance and engagement are common. In some cases, cadavers are abandoned midway through the course, possibly due to psychological, social, or structural barriers. Understanding medical students' attitudes and perceived social norms toward cadaveric dissection is crucial for improving educational experiences and outcomes.

Objective

This study explored the attitude and subjective norm of medical students at Makerere University toward cadaveric dissection.

Methods

Qualitative study design was employed, using seven Focus Group Discussions (FGDs) with first- and second-year medical students. Participants were purposefully selected to ensure diversity in gender and academic experience. Data were transcribed verbatim and analyzed thematically. Ethical approval was obtained, and measures to ensure participant anonymity and psychological support were implemented.

Results

Students’ attitudes toward cadaveric dissection varied from strong enthusiasm and appreciation of its educational value to anxiety, fear, and emotional discomfort. While some viewed dissection as essential for learning, others expressed moral, religious, and psychological concerns. State of cadavers, peer influence, faculty support, and cultural beliefs, significantly influenced students change of attitude resulting to active participation or disengagement with cadaveric dissections.

Conclusion

Findings informed the development of the Integrated Model of Cadaveric Engagement, which highlights the complex interplay of psychological, social, and structural factors influencing dissection behavior.

Introduction

Human anatomy is widely regarded as a cornerstone of medical education, forming the foundational basis for clinical competence and safe practice. ¹ Typically introduced in the preclinical years, anatomy bridges theoretical knowledge and clinical application. Unlike other foundational sciences, it demands distinctive pedagogical approaches most notably, cadaveric dissection, which remains a valued and immersive method for developing spatial understanding and professional identity. ²

Cadaveric dissection remains the gold standard in anatomical education, offering students an irreplaceable three-dimensional and tactile experience that fosters spatial understanding of human structures something digital simulations struggle to replicate. ³ Beyond anatomical comprehension, dissection cultivates technical skill, professional identity, and emotional resilience, shaping students’ early encounters with death, ethics, and empathy.^4,5

The historical use of human cadavers in medical education dates back to the third century BCE, when pioneers such as Herophilus and Erasistratus conducted formal dissections in Alexandria. The practice re-emerged in medieval Europe, particularly in the anatomical theaters of Bologna, Padua, and Paris, and gained prominence during the Renaissance through the works of Vesalius and others. ⁶ Legal frameworks such as the Anatomy Act of 1832 in the United Kingdom and the Uniform Anatomical Gift Act of 1968 in the United States later institutionalized cadaver use for teaching and research, marking a broader shift toward ethical regulation in anatomical science. ⁷

While some institutions have transitioned toward digital alternatives or hybrid formats, cadaveric dissection remains central in many settings particularly in low-and middle-income countries (LMICs) due to its pedagogical value, affordability, and continued reliance on unclaimed or institutionally donated bodies. ⁷ At Makerere University, cadaveric dissection has been a core component of anatomical education since 1924. Traditionally reliant on unclaimed bodies, the program provides students with essential experiential learning that extends beyond technical skill to include reflections on mortality, ethics, and professionalism. ⁸ However, initial exposure to cadavers often elicits strong emotional reactions such as anxiety, fear, and ethical unease shaped by personal values, prior encounters with death, and sociocultural beliefs.^9,10

Recent studies highlight that while some students experience initial emotional discomfort often triggered by the odor or visual appearance of cadavers many gradually adapt and develop a deeper appreciation for the dissection experience.^10,11 Beyond anatomical understanding, cadaveric dissection has been shown to enhance empathy, ethical sensitivity, and emotional maturity, contributing to the formation of professional identity. ¹² Despite these educational benefits, Makerere University has observed a decline in student attendance and engagement in dissection sessions. Numerous cadavers remain partially dissected and abandoned, suggesting a shift in student motivation and attitudes. This growing disengagement signals a need to explore beyond individual or logistical barriers and consider the social and cultural factors influencing learner participation.

Emerging evidence suggests that engagement with cadaveric dissection is shaped not only by personal and emotional factors but also by subjective norms and social pressures—including peer influence, perceived expectations from faculty, and broader societal beliefs about death and the human body.^13,14 These norms shape students’ perceptions of what is acceptable, appropriate, or valued within the learning environment, and may either foster or hinder active participation. ¹⁵ However, little is known about how such norms operate in low-resource, culturally diverse settings such as Uganda. Understanding these dynamics is crucial for developing targeted strategies to improve engagement and sustain the pedagogical value of dissection.

Methodology

This study adhered to the Standards for Reporting Qualitative Research (SRQR) to ensure the methodological rigor and clarity of qualitative research practices. The SRQR framework guided the development, execution, and reporting of the study, promoting transparency, coherence, and credibility throughout the research process. The methodology section details the procedures undertaken in data collection, processing, analysis, and validation. It includes the tools and techniques employed to capture participant perspectives, as well as strategies implemented to ensure the reliability and trustworthiness of the findings. By aligning with SRQR, the study establishes a robust foundation for qualitative inquiry and underscores the importance of adhering to established reporting standards.

Theoretical Framework

This study employed the Theory of Planned Behavior (TPB) as its guiding framework to explore how medical students’ engagement with cadaveric dissection is shaped by personal, social, and cognitive factors. The TPB, developed by Ajzen, ¹⁶ posits that behavioral intention a key predictor of actual behavior is influenced by three primary constructs: attitude toward the behavior, subjective norms, and perceived behavioral control.

According to TPB, attitudes develop from individuals’ beliefs about the outcomes of a behavior and their evaluations of these outcomes. For example, a student who believes cadaveric dissection enhances their understanding of human anatomy is likely to form a positive attitude toward it. Conversely, associations with discomfort, odor, or ethical concerns may lead to negative attitudes ¹⁷

Subjective norms refer to perceived social pressures from peers, faculty, or cultural expectations regarding engagement in dissection. These norms are especially influential in communal societies where decisions are strongly affected by collective opinion. ¹⁶

Perceived behavioral control involves students’ confidence in their ability to manage the technical and emotional challenges of dissection. This includes access to resources, prior exposure to death, and emotional preparedness. ¹⁸

The study also considers the dynamic process of emotional desensitization and attitudinal shift. Initially, students may respond with anxiety, fear, or revulsion. However, repeated exposure and the use of coping strategies such as relaxation techniques and guided reflection can reduce emotional discomfort and gradually foster more adaptive attitudes. ¹⁹

Attitudes are not static; they evolve over time through experience, reflection, and social reinforcement. Pickens ²⁰ highlights that attitudes, though influenced by early socialization, can be changed through targeted educational interventions and positive reinforcement. As students gain confidence and reframe their perceptions of dissection, their engagement tends to increase.

Building on the established framework of the TPB, this study employed a model (Figure 1) to illustrate the relationships between key constructs and student engagement in cadaveric dissection. The model posits that exposure to cadaveric material influences the three core TPB constructs; attitude, subjective norms, and perceived behavioral control, which in turn predict a student's intention to engage in dissection and their subsequent behavior.

Figure 1.

The Framework.

Study Design

This study employed a qualitative cross-sectional design, guided by the constructivist paradigm, which emphasizes the active construction of knowledge through social interactions and contextual experiences. ²¹ This paradigm provided an ideal framework for exploring students’ subjective perceptions and attitudes toward cadaveric dissection, enabling a detailed understanding of the social, cultural, and educational factors influencing their engagement.

Researcher Characteristics and Reflexivity

The research team consisted of experts in qualitative research and anatomy education, blending methodological expertise with subject matter knowledge to ensure both rigor and sensitivity in exploring students’ experiences. While focus group discussions (FGDs) were facilitated directly by the researchers, measures were taken to foster an open and unbiased environment, enabling participants to share freely.

Reflexivity was central to the research process. Researchers critically examined their roles, assumptions, and interactions throughout the study, reflecting on how these factors might influence data collection and analysis. Maintaining reflective journals allowed the team to document potential biases and decisions systematically, ensuring transparency and enriching the interpretation of findings. This practice aligned with the constructivist paradigm's emphasis on co-constructed knowledge, enabling a deeper understanding of participants’ subjective realities.

Through the integration of methodological rigor and reflexive practice, the study achieved objectivity while effectively capturing the intricacies of students’ attitudes and experiences with cadaveric dissection.

Context

This study was conducted in the Department of Human Anatomy at Makerere University College of Health Sciences, founded in 1923 following the establishment of the Medical School in 1922. Since its inception, the department has prioritized cadaver-based dissection as a core component of anatomy education for first- and second-year medical students, supported by theoretical coursework and foundational biomedical training. Cadavers, typically unclaimed bodies from university teaching hospitals, provide students with essential hands-on experience. ¹³

The study focused on first- and second-year students, a pivotal stage when learners transition from theory to practice and begin developing professional identity. This period is characterized by academic stress, emotional adjustment, and evolving coping mechanisms. Capturing student attitudes at this stage offers insights into factors shaping engagement and identity formation.

Emphasis on early clinical exposure, communication skills, and biomedical sciences makes this phase ideal for understanding perceptions of the medical profession. Such insights help inform curriculum interventions and support services that foster student wellbeing and professional growth. Makerere's long-standing dissection tradition highlights its commitment to experiential anatomical education, cultivating technical competence, emotional resilience, and respect for the human body.

Sampling Strategy and Participants Characteristics

All first- and second-year medical students were eligible to participate in the study. Participation was voluntary and based on individual interest, with registration coordinated through class leaders. A total of 122 students initially expressed interest and were allocated to 10 focus groups, each with a scheduled session.

However, actual participation was lower than anticipated due to overlap with the academic examination period. Ultimately, eight FGDs were conducted, each comprising average of 7 participants. Data saturation was achieved by the fifth FGD, when no new themes emerged; however, discussions continued through the eighth session to ensure thematic consistency and demographic diversity.

Participants represented a range of demographic and educational backgrounds: 40% were female, with an age range of 21 to 40 years; 95% were direct entrants from secondary school, while 5% held prior diplomas. In terms of religious affiliation, 78% identified as Christian, 18% as Muslim, and 4% as belonging to other faiths. This diversity supported a rich exploration of perspectives and enhanced the trustworthiness of the findings. The sample composition aligns with best practices in qualitative research aimed at capturing a broad range of experiences and beliefs. ²²

Ethical Issues

Ethical approval for the study was obtained from the institutional review board, ensuring compliance with ethical standards. All participants provided informed consent before their involvement. Measures were carefully implemented to safeguard participant confidentiality and secure data throughout the study process.

Sensitive topics, including religious beliefs and emotional discomfort related to dissections, were approached with empathy and respect. Researchers created an environment that encouraged open communication, allowing participants to share their experiences without fear of judgment or harm. This adherence to ethical principles reinforced the integrity and reliability of the study.

Data Collection Methods

FGDs were conducted in a quiet, well-prepared room within the Department of Human Anatomy to ensure a conducive environment for meaningful conversations. Icebreaker activities, such as light-hearted introductions or brief team-building exercises, were employed at the beginning of each session to help participants feel relaxed and engaged. Sessions lasted between 40 and 60 min, with an average duration of 50 min.

The facilitator, who gained experience and confidence through a pretest conducted at Soroti University, skillfully guided the discussions. This pretest allowed him to refine the discussion guide and enhance techniques for managing group dynamics and fostering open communication. The facilitator minimized intervention to encourage participants to freely share their perspectives.

Predefined open-ended questions were utilized to steer the discussions. Sensitive topics were approached with empathy and respect, ensuring participants felt comfortable engaging in meaningful dialogue.

Data Collection Tools and Technologies

High-quality audio recording devices were employed to ensure precise capturing of FGDs, with clarity and accuracy maintained during transcription. Backup strategies, including the use of secondary recording devices and detailed note-taking, were implemented to safeguard against technical issues.

Predefined interview guides provided structure to the discussions, offering a consistent framework for exploration while allowing for iterative refinement based on emerging themes identified in early FGDs. These refinements ensured relevance and adaptability throughout the data collection process.

Icebreaker activities, such as introductions and engaging team-building exercises, helped participants feel comfortable and at ease, fostering a relaxed atmosphere for meaningful dialogue. Probing techniques, including follow-up questions and prompts like “Can you elaborate on that?” encouraged deeper, more insightful responses, enriching the data collected.

Ethical considerations were integrated into the use of data collection tools and technologies. All participants provided consent for audio recording, and confidentiality measures were strictly adhered to, reinforcing trust and integrity in the research process.

Units of Study

The study included eight FGDs involving a total of 62 participants. These participants were first- and second-year medical students selected to represent varying levels of exposure to medical education, ensuring a balanced perspective on the study topics. Demographics such as age, gender, academic qualifications, and religious beliefs were carefully documented to provide contextual depth to the findings and to enhance the complexity and diversity of the data.

This diverse representation allowed for a thorough understanding of participants’ experiences and perspectives, aligning with the study's objective to capture the multifaceted nature of early medical education experiences. By including participants from varied backgrounds, the research aimed to generate findings that are both comprehensive and reflective of the broader student population.

Data Processing

Audio recordings of focus group discussions were transcribed verbatim by the researcher, ensuring meticulous attention to detail and accuracy throughout the transcription process. To safeguard participant identities, transcripts were anonymized immediately upon completion of transcription. The anonymized data was then securely stored in a robust data management system, adhering to strict confidentiality protocols.

The researcher implemented rigorous data integrity checks by cross-referencing the audio recordings with the transcripts, ensuring consistency, and reliability. Additional measures, such as reviewing transcripts multiple times, were employed to confirm completeness and address any discrepancies. These thorough processes provided a strong foundation for the subsequent qualitative data analysis.

Data Analysis

Thematic analysis was employed to systematically identify, analyze, and report patterns within the data. Creswell's hierarchical framework provided a structured guide for the coding and categorization process. Keywords, phrases, and passages were meticulously coded by the researchers, with codes subsequently grouped into broader themes to encapsulate key insights aligned with the study's research objectives.

The refinement of themes was achieved collaboratively, with researchers engaging in iterative discussions to ensure consistency and coherence throughout the analytical process. Supporting quotations from participants were included to illustrate the identified themes, grounding the findings in the data and connecting them to the research questions.

To maintain rigor, the analysis incorporated reflective notes from the researcher, allowing for acknowledgment of potential biases and enhancing the depth of interpretation. Additionally, peer feedback and cross-verification of themes were integrated as validation techniques, ensuring the accuracy, reliability, and richness of the results.

Techniques to Enhance Trustworthiness

Trustworthiness was rigorously established using several strategies aimed at strengthening the credibility, dependability, and transparency of the research. Member checking involved participants reviewing findings to ensure they accurately reflected their perspectives and experiences. Triangulation was achieved by synthesizing data from diverse participants, iterative focus group discussions, and reflective researcher notes, fostering robust corroboration of findings from multiple sources. A comprehensive audit trail documented decisions made during data collection and analysis, ensuring transparency and accountability throughout the research process. Pretests of data collection tools, such as interview guides, were conducted to enhance their clarity, relevance, and effectiveness. Additionally, a biostatistician critically examined the data analysis methods and outcomes, validating the reliability and rigor of the analytical process.

Results

This section presents key findings from the study, highlighting students’ emotional responses, coping strategies, and evolving attitudes toward cadaveric dissection. The results are organized thematically and grounded in student reflections, offering insight into how learners navigate the emotional, social, and educational dimensions of this formative experience. The thematic map below synthesizes these findings using the TPB framework, illustrating how attitudes, subjective norms, and perceived behavioral control interact to shape students’ engagement (Figure 2).

Figure 2.

Thematic Map: Showing Influences on Medical Students' Engagement with Cadaveric Dissection.

This thematic map above is grounded in the TPB, organizing findings into three interconnected domains:

• Attitude toward Dissection reflects students’ emotional progression—from initial discomfort and anxiety to professional appreciation—shaped by exposure, ethical reflection, and self-reframing.

• Subjective Norms capture the influence of peers, instructors, cultural beliefs, and religious frameworks on students’ decisions to engage or disengage from cadaveric dissection.

• Perceived Behavioral Control encompasses both internal strategies (eg, self-counseling and emotional distancing) and external factors (eg, cadaver quality, lab infrastructure, and mentorship) that facilitate or hinder student participation.

Emotional Responses to Cadaver Dissection

Medical students’ emotional reactions to cadaveric dissection reveal a profound journey of adaptation and growth. Initially, many students experience fear, anxiety, and discomfort, reflecting the psychological impact of confronting mortality and the unfamiliarity of handling human remains. These emotions often provoke deeper reflections on life, death, and human dignity, as students grapple with the ethical dimensions of learning from donated bodies. One student described this confrontation: “I was so excited, but the moment I saw the dead body, everything changed. The excitement disappeared, and fear took over.”

Over time, these initial reactions evolve into curiosity, respect, and professional detachment, facilitated by repeated exposure and supportive learning environments. Students begin to appreciate the privilege of learning from cadavers, recognizing their value as educational resources. This transition underscores the importance of emotional resilience and guided reflection in enhancing cognitive engagement and learning effectiveness. As one student expressed: “At first, I felt bad. I felt like it was inhuman… But now, I understand its importance. It's part of learning. It's part of becoming a doctor.”

The excitement of entering medical school and the anticipation of cadaveric dissection as a rite of passage further amplify the emotional stakes. For many, the anatomy lab represents the first tangible step toward becoming a doctor, blending enthusiasm with nervousness. One student shared: “I was so eager to enter the anatomy lab! I had heard so many stories about dissections, and I imagined myself standing over a cadaver, carefully studying every muscle and organ.” However, the reality of the first encounter often shifts emotions from excitement to fear, highlighting the need for preparatory measures to ease this transition.

The physical and psychological challenges of the dissection room, such as the strong chemical fumes and the sight of preserved bodies, add to the intensity of the experience. Students reported reactions ranging from dizziness and nausea to fainting, emphasizing the need for structured support systems to help them navigate these challenges. As one participant recounted: “I was so scared, I couldn’t even go near it. The room was dark, and the body looked huge. I tried to console myself, but I sat for an hour in shock.”

These findings highlight the multifaceted nature of cadaveric dissection, blending technical learning with emotional and ethical growth. By fostering supportive environments and encouraging reflective practices, educators can help students overcome initial fears and develop the resilience needed for their medical careers. Let me know if you'd like further elaboration or adjustments!

Overcoming Fear and Building Confidence

The journey of overcoming fear and building confidence in cadaveric dissection reflects a profound process of adaptation and growth. Initially, many students experienced trauma and shock, as the reality of working with human cadavers challenged their emotional resilience. One student described this initial reaction: “I was very scared, but then when they opened, they didn't look really bad. They looked like dummies… Because they were very dry, I tried touching with my pen, and the skin was very hard, so the fear, there and then disappeared. It didn’t look real…” This illustrates how the initial fear was rooted in both psychological and sensory unfamiliarity.

Repeated exposure to the dissection process played a pivotal role in reducing anxiety and discomfort. As students gained more experience, they developed coping mechanisms to manage their emotional responses. Self-counseling emerged as a key strategy, with one student sharing: “I kept telling myself, ‘You chose this profession. This is what you signed up for.’ The more I said it, the less afraid I felt.” This cognitive reframing allowed students to align their emotional responses with their professional aspirations.

Peer support and instructor guidance were instrumental in facilitating this adaptation. Observing classmates confidently engage with cadavers provided reassurance and motivation, while instructors offered structured mentorship to normalize the experience. One student noted: “I got the courage from the senior students, my attitude changed, and I started dissecting.” Another added: “When you come and find all your classmates inside, then you sort of also get the strength to.” These shared experiences highlight the importance of a collaborative and supportive learning environment.

Over time, students not only overcame their initial fears but also developed a sense of confidence and competence in handling cadaveric material. This transformation was often accompanied by a shift in perspective, as students began to appreciate the educational and ethical significance of cadaveric dissection. One student summarized this evolution: “At first, I felt bad. I felt like it was inhuman. Like, it's something unnatural. But now, I understand its importance. It's part of learning. It's part of becoming a doctor.”

For many, this journey reaffirmed their calling as future doctors. The ability to overcome fear and discomfort became a testament to their dedication to medicine and their commitment to the lives they will one day save. This process not only built emotional resilience but also laid the foundation for their professional growth and identity.

Coping With Cadaveric Dissections

The transition from theoretical learning to hands-on cadaveric dissection was marked by intense emotional responses among medical students. Many described their initial encounters as overwhelming, with reactions ranging from psychological distress to physical symptoms such as nausea, dizziness, and trembling. One student reflected on their first experience: “The trauma and shock I had before seeing a cadaver is not there now, but at first, I was frozen in place. My mind knew this was a body donated for learning, but my emotions were saying something else entirely.” This highlights the emotional complexity of engaging with human remains for the first time.

Over time, students developed coping mechanisms to manage their discomfort and adapt to the dissection process. Physical interaction with cadavers, such as touching or using tools, emerged as a pivotal strategy for overcoming fear. One participant shared: “I used my pen to poke the skin first, then slowly gained the courage to touch it. That moment changed everything for me.” This gradual exposure helped students reframe their perceptions and build confidence.

Self-counseling techniques also played a significant role in helping students navigate their emotional responses. By reminding themselves of their professional aspirations and the educational value of dissection, many were able to push through their initial fears. As one student noted: “I kept telling myself, ‘You chose this profession. This is what you signed up for.’ The more I said it, the less afraid I felt.” Cognitive reframing, where students viewed dissection as a learning opportunity rather than an emotionally distressing experience, further facilitated their adaptation.

Peer support and social learning were equally influential in fostering resilience. Observing classmates confidently engage with cadavers provided reassurance and motivation, creating a collaborative environment that normalized the experience. One student remarked: “Seeing my classmates dissect without fear gave me the courage to participate.” This collective encouragement underscores the importance of supportive learning environments in anatomy education.

These findings reveal the complex nature of coping with cadaveric dissection, blending individual strategies with social and educational support systems. By addressing these emotional challenges, medical educators can help students build resilience and confidence, ultimately enhancing their learning outcomes and professional development.

Student Disengagement From Cadaveric Dissections

The poor quality of cadavers emerged as a significant factor contributing to student disengagement during dissection sessions. Many students expressed frustration with the condition of the cadavers, which hindered their ability to locate anatomical structures effectively. One student remarked: “It wasn't a lot about understanding because now you will have something that is lined up, and whenever we try to dissect, it's like wood. You are just tearing away. You don’t know what you did, we just tear away.” This lack of clarity and precision in the dissection process diminished the educational value of the experience for many.

As a result, some students turned to alternative learning methods, such as online videos, to supplement their understanding. One participant noted: “Some people come and sign attendance, but they are always never there. They go back and get YouTube videos. They watch YouTube where the descriptions are in detail; you find some people prefer watching YouTube than dissecting cadavers.” This reliance on external resources highlights the need for institutions to address the logistical challenges of maintaining high-quality cadaveric specimens.

The repeated failure to locate structures or achieve meaningful progress in dissections further exacerbated disengagement. Students described feelings of futility and frustration, with one stating: “They give up because it's very frustrating. You come, look for something. On the first day, you don’t get it. Second day, you don’t get it. They would say, why should I continue dissecting? You find bodies are rotten or very dry.” These experiences underscore the importance of providing well-preserved cadavers and ensuring that students have the tools and guidance necessary to succeed.

Addressing these challenges is critical to fostering student engagement and maximizing the educational impact of cadaveric dissection. By improving cadaver quality and integrating complementary learning resources, institutions can create a more effective and motivating learning environment for medical students.

Discussion

Cadaveric dissection continues to serve as a foundational element of medical education, providing students with tactile and spatial understanding critical for clinical practice. Beyond its technical value, dissection introduces learners to deeply humanistic dimensions of medical training, compelling them to engage with questions of mortality, ethics, and cultural meaning. Anchored in the TPB, ¹⁶ this study examined how attitudes, perceived social expectations (subjective norms), and perceived behavioral control shaped students’ engagement with cadaveric dissection in a context characterized by cultural diversity and resource constraints.

Two broad thematic patterns emerged from the data: students’ initial attitudes toward cadaveric dissection, and the evolution of those attitudes over time.

Initial Attitudes and Early Challenges

Upon first entering the dissection hall, many students experienced a mixture of curiosity, excitement, and reverence. Dissection was seen as a milestone in their medical journey a rite of passage that granted access to the anatomical realities of the human body. This perception aligns with findings from other African contexts, where dissection is viewed as essential for developing manual dexterity and anatomical confidence.^23,24 These beliefs reflect positive attitudinal components of the TPB framework, influencing behavioral intentions to actively participate.

Nevertheless, early exposure often triggered emotional discomfort, including anxiety, fear, and physical unease, particularly due to the appearance of preserved cadavers and the sharp odor of formalin. Such responses are well-documented across settings in Ethiopia, Uganda, and Malawi, where dissection is both a pedagogical and emotional challenge for students. ²⁵ Importantly, students’ reactions were not only rooted in individual temperament but were shaped by broader cultural worldviews regarding death and bodily sanctity. Many students entered the dissection environment with limited prior exposure to deceased bodies, and in societies where death is treated with spiritual caution, this lack of familiarity compounded their emotional responses.

Ethical uncertainty also emerged as a persistent concern. Several students expressed unease about the origins of cadavers, citing concerns that the use of unclaimed bodies lacked informed consent or family recognition. This echoes broader African scholarship that highlights the underdevelopment of body donation programs due to religious stigma, legal ambiguity, and societal discomfort. ²⁶ These ethical tensions disrupted emotional engagement for some learners, suggesting that culturally sensitive institutional rituals such as opening ceremonies and ethics briefings may help establish a shared moral framework early in the dissection experience.

In addition to emotional and ethical tensions, institutional conditions affected students’ perceived behavioral control. A recent study in southwestern Uganda revealed that the majority of cadavers used in medical training were unclaimed bodies, poorly preserved, and lacked proper labeling, these challenges compromised learning experiences and limited the ability to confidently identify anatomical structures. ²⁷ These findings resonate with participant narratives in this study, where students described feeling disoriented, frustrated, or unmotivated in the absence of well-prepared specimens and reliable instructional support. For some, these frustrations shifted attention toward more structured digital tools, further indicating how perceived control over learning shapes behavioral engagement.

Crucially, social norms are both descriptive (what peers typically do) and injunctive (what respected others expect them to do) layed a powerful role in shaping these early attitudes. Students paid close attention to how their classmates, senior peers, and instructors responded to dissection. Watching others engage with composure or even enthusiasm provided behavioral cues that helped normalize the environment. Faculty encouragement and ethical framing also signaled that participation was not only expected, but professionally and morally appropriate.

Adaptation and Attitude Change Over Time

Despite the initial discomfort, most students experienced a shift in perception as their engagement deepened over time. Repeated exposure allowed them to gradually reduce emotional reactivity, refine their dissection techniques, and view the cadaver with increasing respect and clinical focus. These changes illustrate how emotional regulation, peer reinforcement, and instructor support interact to reshape attitudes and behaviors, enhancing motivation and perceived capability.

Social interaction was critical to this transformation. Peer learning, informal debriefs, and group-based dissection helped students process fear and uncertainty in a supportive setting. These descriptive norms observing peers managing dissection tasks successfully reinforced a sense of shared experience and contributed to a growing belief that “if others can do it, so can I.” This aligns with literature emphasizing the importance of peer dynamics in normalizing challenging professional experiences.^1,28

Instructor presence and guidance also played a central role in reinforcing injunctive norms and shaping learning experiences. Faculty members who provided structured demonstrations, acknowledged students’ emotions, and modeled professional behavior helped foster moral clarity and psychological safety. Bhattarai et al ²⁹ found that learners who receive both technical instruction and emotional mentorship during dissection are more likely to adopt a constructive, growth-oriented mindset. Small group teaching formats, particularly those incorporating peer discussion and guided facilitation, have proven effective in fostering both precision and reflective engagement in anatomy education. ³⁰

Another key theme was the use of emotional coping strategies—particularly cognitive reframing. As students spent more time in the lab, many adopted symbolic language (eg, “silent teacher” or “medical gift”) that allowed them to humanize the cadaver while reducing emotional distress. These reframing mechanisms, observed in other African contexts, ²³ were often developed and reinforced socially, further highlighting the formative role of peer culture.

Importantly, this growth extended beyond technical learning. By navigating emotional discomfort, ethical ambiguity, and peer expectations, students reported feeling more confident, compassionate, and professionally mature. These reflections support previous work suggesting that cadaveric dissection contributes meaningfully to the development of empathy, ethical sensitivity, and psychological resilience among medical trainees.^31,32

Taken together, the findings reinforce the central role of social norms in shaping medical students’ behavior during cadaveric dissection. They influence how discomfort is expressed or concealed, how learning is approached, and how ethical meaning is constructed. Within the Integrated Cadaveric Engagement Model, social norms do not operate in isolation but interact dynamically with attitudes, institutional settings, and emotional regulation strategies—ultimately guiding students toward deeper, more meaningful forms of professional engagement.

The Integrated Model of Cadaveric Engagement

The findings of this study culminated in the development of the Integrated Model of Cadaveric Engagement (IMCE) as contextualized extension of Ajzen's Theory of Planned Behavior, ¹⁶ tailored specifically to the anatomy laboratory setting. While the original TPB provides a robust framework for understanding intention and behavior through the lens of attitudes, subjective norms, and perceived behavioral control, it does not fully account for the emotionally charged, ethically sensitive, and institutionally complex landscape of cadaver-based education. The IMCE addresses this gap by introducing constructs specific to the dissection experience, synthesizing insights from psychological theory, medical humanities, and anatomical pedagogy.

Dissection as an Affective and Cognitive Encounter

Cadaveric dissection is more than a technical exercise; it is a deeply affective and transformative educational encounter. Often described as a “rite of passage,” it exposes medical students to mortality, human vulnerability, and the embodied nature of clinical practice. While past studies have highlighted cognitive benefits and emotional responses, few theoretical models explicitly account for the interplay between affect, cognition, and behavior in this context. The IMCE integrates emotional resilience and sensory adaptation into the domain of perceived behavioral control, emphasizing that control is not merely physical confidence but also psychological readiness.

Resilience, in this context, is not a static trait but a skill nurtured through institutional and social scaffolding such as structured orientation, guided reflection, peer reassurance, and ethical dialogue. Students who are unprepared or unsupported may disengage or become emotionally desensitized, whereas those who receive guidance are more likely to develop mature, compassionate forms of professional engagement.

Cognitive and Ethical Dimensions of Attitude Formation

Unlike TPB's unitary conception of “attitude,” the IMCE differentiates between cognitive associations such as linking dissection with clinical skills and ethical or cultural beliefs, such as reverence for the body or discomfort rooted in spiritual taboos. These belief systems are not static; they evolve through curricular exposure, group interaction, and institutional practices. For instance, students from collectivist traditions may face internal tension between personal values and perceived group expectations. This intrapersonal negotiation affects both behavioral intention and emotional alignment during dissection.

Educational strategies that humanize the cadaver, facilitate cross-cultural dialogue, and connect anatomical learning to future caregiving roles can positively shape students’ moral frameworks and professional identity. Institutions that promote such strategies help move learners from passive compliance to intentional engagement.

Social Norms as Mediators of Engagement

The IMCE also reframes subjective norms to highlight the active role of social learning and peer culture. Behavioral shifts were often prompted not by formal instruction alone, but by informal group dynamics seeing peers approach dissection with calm or hearing classmates affirm the value of participation. These descriptive norms operated alongside injunctive norms from faculty, creating a multi-tiered system of encouragement and expectation that helped students reinterpret their emotional responses and refine their engagement over time.

Structural and Institutional Influences

Finally, the IMCE recognizes that engagement is shaped by institutional factors often overlooked in behavioral models. Cadaver quality, access to instructional guidance, and physical safety such as protection from formalin exposure to create a practical environment in which behavioral intention is either supported or undermined. The model argues that these structural variables can interact with psychological and social determinants, amplifying or attenuating students’ ability to engage meaningfully.

Figure 3 below presents the Integrated Cadaveric Engagement Model, visually representing the layered psychological, social, ethical, and institutional factors that influence students’ behavior during cadaveric dissection. Drawing on the TPB and complementary learning theories, it illustrates how emotional regulation, peer modeling, ethical belief systems, and instructional quality coalesce to foster intentional engagement, professional formation, and ethical sensitivity.

Figure 3.

Subjective Norms and the Power of Institutional Culture.

Subjective Norms and the Power of Institutional Culture

While peer modeling plays a crucial role in shaping behavior, the IMCE expands the construct of subjective norms to include institutional ethos, faculty conduct, and ceremonial practices that together cultivate a shared professional culture. The presence or absence of formal rituals, such as donor memorial services or moments of silence, powerfully shapes how students interpret the ethical weight of cadaveric learning. Likewise, the emotional tone set by faculty during lab sessions can either reinforce dissection as a dignified rite of passage or trivialize it as routine technical work.

Institutional support strengthens normative engagement when faculty actively participate in reflective discussions, address emotional and ethical challenges openly, and align instructional delivery with broader curricular values. Conversely, students may internalize a sense of detachment or ethical ambiguity when confronted with poor cadaver quality, crowded labs, or dismissive faculty attitudes. These findings illustrate that subjective norms are co-constructed through both social interaction and institutional symbolism.

Structural and Environmental Influences

The IMCE also foregrounds structural conditions as key determinants of cadaveric engagement. Factors such as cadaver availability, preservation quality, dissection room facilities, access to protective equipment, and faculty-to-student ratios significantly shape emotional readiness and perceived behavioral control especially among first-time dissectors. Students frequently described how logistical shortcomings disrupted not only their focus, but also their moral and emotional equilibrium.

Importantly, curriculum design intersects with these conditions. Programs adopting problem-based learning, spiral curricula, or digital dissection tools must assess whether these innovations enhance or dilute the ethical, emotional, and sensory components traditionally embedded in cadaveric dissection. The IMCE offers a critical lens for evaluating such curricular decisions, encouraging educators to consider not only what is taught, but how and under what conditions students engage.

Comparing TPB and IMCE: A Theoretical Advancement

The development of the IMCE was informed by the limitations of the traditional TPB when applied to emotionally and ethically charged learning environments. While TPB has offered a foundational lens to examine behavioral intention, it does not fully account for the affective, cultural, and structural complexities of cadaveric dissection in diverse educational settings. Table 1 below compares the key dimensions of TPB and the IMCE, highlighting how the latter offers a more context-sensitive framework for understanding medical students’ engagement in dissection-based anatomy education.

Table 1.

Comparing TPB with IMCE.

Dimension	Theory of planned behavior (TPB)	Integrated model of cadaveric engagement (IMCE)
Attitude	General beliefs about behavioral outcomes	Expanded to include cognitive associations (eg, relevance to medicine) and ethical/cultural beliefs
Subjective norms	Perceived social pressure from significant others	Includes peer and institutional norms, faculty influence, and curricular rituals like donor memorials
Perceived behavioral control	Perceived ease/difficulty of performing behavior	Includes emotional resilience and sensory adaptation essential to cadaveric coping
Contextual sensitivity	Limited focus on institutional context	Emphasizes structural factors: cadaver quality, curriculum, faculty support
Affective dimension	Implicit or secondary	Centralized, highlighting grief, empathy, stress, and adaptation
Applicability	Broad behavioral settings	Specific to dissection, but adaptable to emotionally charged learning environments

This comparison illustrates that while the TPB offers a strong behavioral foundation, the IMCE provides a more nuanced, education-specific model grounded in students’ lived experiences. Its constructs emerged inductively through thematic analysis, responding to gaps in existing psychological frameworks while offering fresh insights into educational behavior in emotionally demanding contexts.

Reframing Engagement Through Emotional and Ethical Lenses

In the IMCE, perceived behavioral control is re-conceptualized to include emotional resilience and sensory adaptation. Dissection can provoke acute emotional responses anxiety, moral discomfort, and grief all of which influence motivation and participation. Students who develop adaptive coping strategies, often through peer support or guided reflection, show greater perseverance and meaning-making. Similarly, gradual sensory exposure adjusting to sights, smells, and textures builds tolerance and self-efficacy over time.

The model also reconceives attitude as a fusion of cognitive associations and ethical beliefs. Students who view dissection as essential to developing clinical skills and empathy tend to express positive, engaged attitudes. Yet attitudes may be negatively shaped by cultural or religious prohibitions regarding the human body, death, or spiritual defilement. Unlike TPB's unidimensional treatment of attitudes, the IMCE accounts for these complex value conflicts and their behavioral implications.

Moreover, subjective norms are expanded to encompass the full social ecology of the dissection room. Faculty who demonstrate empathy, uphold ethical conduct, and engage in ceremonial teaching help establish a shared moral framework. Events such as donor memorials and pre-dissection orientations signal institutional respect, reinforcing normative alignment and encouraging reflective participation.

Finally, structural influences often downplayed in traditional behavioral models are treated as central in the IMCE. Access to well-preserved cadavers, proper ventilation, learning materials, and psychological safety all shape whether students feel they can and should engage. These environmental factors interact dynamically with internal states, often determining whether behavioral intentions translate into sustained action.

Implications for Medical Education

The Integrated Model of Cadaveric Engagement offers a multidimensional framework that bridges behavioral psychology with educational practice. It challenges the notion that dissection is purely a technical exercise, reframing it as an emotionally rich, ethically complex, and socially regulated learning experience. Effective engagement, the model suggests, requires deliberate institutional scaffolding not only of knowledge and technique, but also of emotional preparedness, moral reflection, and cultural sensitivity.

Educators can operationalize this model by:

• Incorporating structured emotional debriefing and guided reflection;

• Facilitating peer-led discussion groups to strengthen positive social norms;

• Designing inclusive curricula that recognize cultural and spiritual diversity;

• Providing faculty development on trauma-informed and ethical instruction; and

• Addressing structural deficits that undermine learner confidence or comfort

Directions for Future Research

Future research can strengthen the model's applicability and empirical grounding. Suggested approaches include:

1. Longitudinal Designs—Tracking cadaveric engagement across semesters to examine shifts in behavior due to adaptation, normative reinforcement, and ethical internalization.

2. Intervention Studies—Comparing outcomes for students exposed to enhanced orientation, mentoring, or structured ethical discourse versus conventional training environments.

These methodologies would provide empirical support for IMCE's predictive utility, deepen understanding of student behavior, and inform practical innovations in medical education policy and curriculum design.

Conclusion

The Integrated Model of Cadaveric Engagement reframes dissection not simply as a technical task, but as a profoundly human learning encounter. By acknowledging how emotion, ethics, institutional culture, and structural realities intertwine, the IMCE offers educators a clearer roadmap for fostering meaningful, respectful, and ethically grounded engagement. It invites medical educators to think not only about how students learn anatomy but also about who they become in the process.

Study Limitations

This study has several limitations. First, as it was conducted solely at Makerere University, the findings may not be fully generalizable to other institutions or cultural settings with differing curricular structures, dissection practices, or sociocultural dynamics. Second, the reliance on self-reported data introduces potential biases, including social desirability and recall bias, which may have influenced how participants articulated their emotional responses and engagement. Third, the study did not incorporate longitudinal tracking or formal psychological assessments, which could have enriched the understanding of how attitudes evolve over time or the potential mental health impacts of cadaveric dissection. However, the influence of researcher positionality may have subtly shaped data interpretation but not participant interaction, since the data collector wasn’t among the teaching staffs of the department.