Medical student learning in the operating room: a qualitative study from the perspectives of students and the OR team

Abstract

Background

The operating room (OR) is a pivotal setting for medical students, shaping both professional identity and clinical competence. This study explored the expectations and experiences of medical students during their OR training, while also incorporating the perspectives of the surgical team.

Methods

A qualitative study was conducted using focus groups with OR team members and semi-structured interviews with medical students. Data were analysed using a conventional content analysis approach, with findings organised into higher-order categories to capture shared and divergent perspectives on learning, supervision, and team dynamics.

Results

Students described how interactions with the OR team, clarity of expectations, and opportunities for participation shaped their learning experiences and professional identity. Orientation was consistently reported as a critical need, and both students and educators supported the development of a self-paced e-learning module to address this gap. While students appreciated supportive supervisors, they also reported that unclear expectations and inconsistent guidance generated stress and uncertainty. Negative behaviours emerged as a barrier to motivation and learning. From the OR team perspective, heavy workload, time pressure, competing clinical priorities and unclear expectations were described as factors influencing educational interactions.

Conclusions

The findings suggest that enhancing orientation processes, attention to role expectations, and supportive interprofessional interactions may influence medical students’ learning experiences in the OR.

Background

The operating room (OR) is a key setting for undergraduate medical education. It offers diverse learning opportunities, including surgical skills, anaesthesia management, critical thinking, teamwork, communication, patient safety, sterilisation, and crisis resource management [1, 2]. However, students often fail to benefit from this rich environment fully and frequently report negative learning experiences [3, 4]. This gap has been attributed in the literature to factors such as unclear learning objectives, unprofessional behaviours from healthcare staff, lack of appropriate role models, high clinical workload, and the inherently stressful nature of the OR [5, 6].

Most studies examining medical student education in the OR focus primarily on the perspectives of surgeons and students, often overlooking the integrated views of the broader OR team, including anaesthetist and nursing staff [5–7]. However, the culture and interpersonal dynamics within the OR team have been shown to shape students’ learning experiences. Irani et al. identified a lack of role clarity as a major barrier to effective educational interactions and emphasised the importance of incorporating OR staff perspectives to fully understand the learning environment [8]. A study that synthesises the entire OR team’s view may offer valuable insights into contextual and structural factors that can help to ensure that students derive meaningful educational benefits from OR-based training.

In this study, we aimed to explore the challenges encountered during medical students’ training in the OR, as experienced by students, supervisors, and other OR team members. We also sought to identify practical strategies proposed by these stakeholders to improve the teaching and learning environment in the OR. Our research questions were as follows:

• (i)What specific challenges are encountered during medical students’ training in the OR, and how are they experienced by the students and OR team members?
• (ii)What strategies do students and OR team members propose to improve the educational environment in the OR?
• (iii)How do students interpret and respond to these challenges?

Methods

We conducted an exploratory qualitative study using focus groups and interviews to explore the complexities and dynamics of teaching and learning in the OR. The study was conducted at a tertiary university hospital in Rize, Türkiye, with data collected between 19 April and 17 May 2022.

Participants

We purposively sampled OR team members who served as departmental representatives on the faculty’s educational board, as these individuals have formal responsibility for undergraduate education and were well placed to comment on both OR practices and educational processes.

In Türkiye, undergraduate medical education spans six years. Clinical training begins in the fourth year, with clerkships in years 4 and 5 and an internship in year 6. We recruited a convenience sample of students from these final three years to reflect diverse OR learning experiences. The sample included an equal number of female and male participants across year groups. Students were invited to participate at specified interview times, and those who were available attended the interviews. No students declined participation; therefore, information on the characteristics of non-participants was not available.

Data collection

The interview questions (Table 1) were developed based on insights gleaned from previous studies [1–3, 6, 9] and the reflective diaries of CK, which documented personal experiences during anaesthesiology residency. To ensure the questions were appropriate and sufficiently comprehensive, they were reviewed by two experienced surgical supervisors. All focus groups and interviews were conducted by CK. Probing and follow-up questions were asked as needed to elicit depth, clarify participants’ responses, and explore emerging issues. Examples of probing included asking participants to provide specific examples, to elaborate on their feelings or experiences, or to clarify the context of interactions. The interviews and focus group discussions were audio-recorded via a digital voice recorder and transcribed verbatim.

Table 1.

Focus group and interview questions

OR team focus group questions

What are the learning objectives of students' training in OR? What kind of practices do you do for training in OR? What are the positive and negative aspects of education in OR? What kinds of problems occur in training in OR? What can be done to improve the quality of education in OR?

Medical Student's interview questions

What do you learn in OR? How does being in the operating room make you feel? What are the problems that occur in OR during your training? What should students, trainers, and the OT team do to improve your learning in OR? What are the positive and negative aspects of training in OR? What can be done to improve the quality of education in OR?

Coding and analysis

We adopted a conventional content analysis approach [10] to identify and synthesise findings from the interview data. Our analysis proceeded in multiple stages. First, the transcripts were read repeatedly by the authors to achieve immersion in the data and to generate initial codes that captured recurring patterns. Second, an iterative coding process was used: transcripts were coded as they were collected, and earlier codes were continuously refined considering emerging insights. Member checking was conducted with six of the interviewed students and three trainers. Their feedback contributed to refining and validating the coding structure, ensuring that it accurately reflected their experiences and emotional responses [11]. During the process of organising these codes into higher-order categories, we drew on established guidance on organising qualitative findings to support coherent presentation of results [12].

To support rigour, two surgical colleagues who were doctoral students in medical education contributed to provide analytic and contextual input. They reviewed a subset of transcripts and discussed the appropriateness of code labels, the alignment between codes and supporting excerpts, and the organisation of codes into higher-order categories. Through iterative analytic discussions, coding decisions were refined and clarified, supporting consistency and coherence across the analysis [13, 14].

Reflexivity

The first author (CK) is an anaesthetist and PhD(c) in medical education. This dual role provided a unique perspective, blending clinical experience with academic inquiry while carrying the risk of normalising certain practices. The second author (BS), a specialist in medical education, provides a different perspective grounded in educational theory and practice. Our diverse backgrounds facilitated a comprehensive approach to the study, offering practical and theoretical foundations for analysing the participants’ experiences. In terms of engaging with our participants in our findings, we aimed to create a culture of continuous improvement by sharing the preliminary results with the medical teaching staff involved in the study.

Reflexive practices were used throughout the process [12]. CK engaged in analytic memoing, documenting emerging interpretations, assumptions, and points of uncertainty during coding. These reflections were revisited during team discussions. In particular, the extent of perceived tension between students and nursing staff emerged more strongly than expected. Although this study did not include nursing staff as analytic collaborators, this reflexive insight informed the design of subsequent work, in which nursing perspectives are being more explicitly incorporated, from the earliest stages of future studies, including the formulation of research questions, data collection strategies, and analytic frameworks.

Results

We conducted two separate focus group interviews with the OR team, each involving 7 participants (total N = 14). The participants included seven surgeons from different departments, three anaesthetists, two surgical nurses, and two anaesthesia technicians. We also conducted 12 semi-structured interviews with medical students, four each from the 4th year, 5th year, and 6th year of medical school (2 male and 2 female from each year).

Our analysis identified a set of analytic categories reflecting key aspects of teaching and learning in the operating room. These categories captured experiences related to OR culture, supervisors and students’ practices, educational structures, professional identity formation and the physical environment. An overview of categories and corresponding codes is provided in Table 2.

Table 2.

Categories and codes

Categories	Codes	Example Quotes	Participant
OR Team Culture	Interpersonal conflicts, team hierarchy, priority clashes, unspoken rules, sacredness, culture, time restraints, scrubbing in, rituals, clothing	“They started calling me ‘doctor’ after I scrubbed in.”	6th year student
Relationships	Negative behaviours towards students, exclusion, encouragement, tensions	“They treat us like we are worth less than a sponge.”	5th year student
Role of Surgical Educators and Students	preoperative briefing, introduction of OR team, pedagogical development of educators, stress and workload of supervisors, confusion about educational objectives, learners’ Preparation, learners’ proactivity, Students’ reflective strategies for improving learning	“Only if the trainer verbally explained his thoughts during surgery. He is thinking, is not he?”	6th-year student
Physical Environment	Cold, facilities, visibility of the surgical field, physical hardships, crowd	“I could not focus on anything and was just shivering because of the cold.”	4th year student
Education Program	E-learning, formal introductions, orientation, shared goals, hidden curriculum, learning objectives, educator skills	“We don’t know what the learning goal is; we just stand and watch	4th year student
Professional Identity Formation	Stress, lack of preparedness, passive roles, professional identity development, feelings	"…we go there with excitement. We change into surgical scrubs, we put on our cap, we put on our slippers… one of the rare moments when we feel like a doctor…"	4th year student

Culture and relationships within the operating room

The students reported one of their most significant problems was the negative behaviours directed towards them by nonphysician health workers. Trainers and surgical nurses also acknowledge this issue:

"I did not know this is how the health workers view us. I learned how they alienated us…" 4^th-year student.

These negative behaviours of the team members seemed to reduce the students' motivation and cause negative learning experiences:

"…like we are worth less than a sponge there...as if we're redundant, worthless…" 5^th-year student.

In contrast, OR team members reported one of their significant concerns related to prioritising patient safety above students’ educational needs, especially those who were not in the supervisory role:

"There is also a risk of complications. You take the procedure from professionals and give it to novice practitioners. Complications may occur... The patient may not receive the best professional care." Anaesthetist

Some OR team participants articulated that some supervisors’ focus on teaching could at times conflict with these responsibilities:

"There may be a complication of anaesthesia. While we are busy with our duty, they may experience serious stress. Sometimes, when we are dealing with severe bleeding on this side of the barrier (drapes), they try to train the students and so on. We can distract each other." Surgeon

However, other OR team participants argued that educational activities should not be consistently deprioritised:

"While I take turns training ambulation to one and making the other do something else, the surgeons rush us to start the surgery. 'Oh, you're late,' they say... While I was trying to train the students, it was not nice to encounter such an attack from the other side. I think that surgical branches should value education more." Anaesthetist

One student reflected on how these experiences shaped perceptions of future professional relationships:

"I heard from many friends that they hated the other health workers. They say, 'They can do it to me now, but they cannot after I graduate..." 6^th-year student.

Participants identified several factors contributing to negative interactions, including crowded student groups, noise, lack of orientation, concerns about safety, unclear student roles, and students not being perceived as part of the team:

"…crowd and noise are the issues that we suffer... Apart from that, one of the problems we experienced with our medical students is that they touch the sterile area." Surgical nurse

If the student’s supervisor trainer introduced them to the team, the team members' behaviour was reportedly more positive. In addition, the supervisor’s behaviour towards the student seemed to affect the perspective of the rest of the team:

"Until the supervisor comes, we are excluded in the OR. They do not even call us by our names. However, they say, 'move,' 'do not touch, 'do not do this, or 'go here.' When the trainer comes, they call us 'doctors.' Everything changes. Then, we start to feel respected by the team." 4^th-year student

However, the instructor's delay in this task may lead the student to have negative experiences with team members:

"…Only on the last day, when my supervisor surgeon communicated with me, the nurses started to call me a doctor.' 4^th-year student

The students and the OR team members described the distinct culture of the OR and the challenges associated with adapting to it. The OR team used words such as "mystical" and "sacred" when referring to the OR setting, whereas the students likened it to an "alien world."

Healthcare duty was described by OR team members as central to the culture of the OR, shaping values, priorities, and interactions. This duty, centred on patient safety and care quality, underpins the OR environment, where actions, protocols, and rules are designed to support patient care. In the focus groups, OR team members noted that time spent teaching students could at times conflict with other team members’ clinical responsibilities. Participants suggested that greater communication within the team regarding educational roles and expectations was needed.

"While I take turns training ambulation to one and making the other do something else, the surgeons rush us to start the surgery. 'Oh, you're late,' they say... While I was trying to teach the students, it was not nice to encounter such an attack from the other side. I think that surgical branches should value education more." Anaesthetist

Participants also described conflicts between clinical responsibilities and educational duties in the OR:

"We wish we had a more organised job. However, unfortunately, we have so much to do in outpatient clinics, and we also have inpatients too. I expect more understanding from the anaesthesia." Surgeon

"On the one hand, patient privacy must be protected. On the other hand, the student should be educated. We do not always get the balance." Anaesthetist

"There is also a risk of complications. You take the procedure from professionals and give it to novice practitioners…" Anaesthetist

The role of surgical educators and students

The students said that the surgical supervisors were friendly and supportive. To enhance their learning in the OR, students articulated clear expectations regarding guidance from supervisors and the team.:

"Everybody has a certain task. However, for us, it is very stressful... we never know what to do." 4^th-year student.

Preoperative briefings were another expectation that students advocate for, suggesting that an understanding of each surgery’s context and objectives of each procedure could allow them to more meaningful engagement with the surgeries.

Students emphasised that being formally introduced to the OR team on their first day could help establish a welcoming atmosphere, facilitating smoother interactions and a greater sense of inclusion. They also reported that being allowed to scrub into surgeries enhanced their sense of involvement and motivation, supporting their integration into the surgical team. In addition, students valued educators “thinking aloud” during procedures, as sharing clinical reasoning helped clarify decision-making processes and procedural steps.

"A student cannot know everything, only speculate. Only if the trainer verbally explained his thoughts during surgery. He is thinking, is not he? He can share his thoughts with us." 6^th-year student

Another suggestion raised by students was the use of technology, such as camera systems, to improve visual access to the surgical field, particularly when direct observation was limited. Beyond observing procedures, students also highlighted the importance of witnessing the patient’s entire perioperative journey, noting that this holistic perspective deepened their understanding of surgical care and patient management from start to finish.

Students highlighted the need for ongoing pedagogical development among educators, noting the value of adaptable teaching approaches that can accommodate diverse learning needs. They also reported that unsupportive attitudes from supervisors reduced their motivation and confidence, negatively affecting their engagement in the OR.

Insights from the OR team focus groups suggested that negative behaviours were often associated with high stress levels, heavy workloads, time pressures, and unclear educational expectations.

Students discussed how their own behaviours affected their engagement in the OR. Several acknowledged that they tended to remain passive and hesitant, and suggested that introducing themselves to the team, asking questions more actively, and reviewing cases beforehand would have helped them engage more effectively.

“I would never be shy. They do not suggest you do something; you need to ask.” 5th-year student.

They also described that communicating with the team before surgery, speaking up when they encountered a problem, and maintaining motivation despite mistakes were strategies they wished they had adopted. However, they also emphasised that the absence of explicit learning objectives for the OR made it difficult for them to know how best to prepare.

Supervisors and OR team members also reported challenges related to students not consistently adhering to OR rules, such as talking during procedures when not scrubbed in. These behaviours were described as being influenced by several factors, including insufficient orientation, limited visibility of the surgical field, inadequate communication from supervisors, unclear learning objectives, and physical constraints within the OR environment. In addition, team members noted the need to frequently remind students not to take photographs in the OR.

Professional identity formation

Students described the operating room as an important context for their professional identity development. All of them reported that time spent in the OR contributed to feeling more like physicians during their training, regardless of their intended specialty. Students described experiencing a heightened sense of responsibility and professional belonging when entering the OR environment Students said they had felt thrilled and proud when they had changed into OR scrubs and wore bonnet:

"…we go there with excitement. We change into surgical scrubs, we put on our cap, we put on our slippers… one of the rare moments when we feel like a doctor…" 4^th-year Student.

"…To witness the patients entrust themselves to the doctor in the OR…I think it can bring the student's enthusiasm back and help us to be aware of the great responsibility." 6th-year Student.

Surgeons also consider the OR significant for helping students develop an identity as physicians.

"I find it mystical that the patients completely surrendered themselves. First, their trust in anaesthesia, their confidence that their pain will be relieved, and the team will treat them well. In this respect, our students learn how valuable their profession is. To know one's privacy, and someone to trust you and lie on the surgical table and let you use a scalpel… It is magical that they let us put him to sleep, cut, cut, stitch..." Surgeon

Embedding educational program in the OR

Participants reported that learning opportunities in the OR included visualising theoretical knowledge in practice, supporting professional identity development, enhancing clinical reasoning, and acquiring both technical and nontechnical skills. However, students frequently described uncertainty regarding their purpose and responsibilities in the OR. One exception was the anaesthesiology clerkship, where supervisors regularly communicated the role of anaesthesia nurses in teaching technical skills to students. In contrast, participants reported that the role of surgical nurses in education was often undefined, which limited their involvement in the teaching process. Surgeons identified sterility as an important learning area that they considered well suited to being taught by surgical nurses. The students, however, described encountering sterility primarily through corrective interactions, such as being reminded not to touch sterile fields rather than through constructive teaching methods.

The students' lack of orientation seems to have negative impacts, including anxiety, reducing their acceptance by the team, and consequently reducing their motivation to learn while the OR team stated it as a patient safety threat:

"On the first day in the OR…we did not know whether we would turn right or left, where to wear a cap, where to change shoes… We were completely lost. We tried to learn by asking but did not know who to ask. That part was horrible." 4^th-year student

"…They (medical students) wander around in the OR. They do not know the rules. We can never be sure whether they will touch the green (drapes)." Surgical Nurse

Members of the OR teams repeatedly mentioned that effective orientation for students is crucial. The orientation should be conducted immediately before entering the OR and should be repeated before every surgical rotation. Participants reported that when students entered the OR without adequate orientation, team members experienced increased concern regarding sterility and patient safety. Supervisors suggested the use of an e-learning resource supported by videos and reading materials, while students expressed a preference for flexible access to orientation content that would allow them to review materials according to their individual learning needs.

Physical environment of the OR

Students identified several structural features of the operating room environment as barriers to learning. These included the cold temperature, lack of designated spaces for students to rest, eat, or change into scrubs, and limited visibility of the surgical field. While members of the surgical team expressed concerns that prolonged standing and the smell of blood might negatively affect students, none of the students themselves raised these issues.

Discussion

Our investigation is among the limited body of research incorporates the perspectives of both the OR team and medical students regarding OR-based training. In line with the findings of Ji et al. [7], our study confirms the concerns expressed by OR nurses about students’ lack of orientation and insufficient competence in maintaining sterile technique.

In our study, OR seems to play a significant role in the development of medical students’ professional identities—an observation explicitly mentioned by all student participants. Prior studies suggest that symbols are central to identify formation in medical training [15]. In our study, the students described how wearing OR attire (scrubs, surgical bonnets) carried a symbolic meaning for their professional identity development. Being permitted to scrub in, rather than solely observing, contributed to their sense of inclusion within the team. Students noted a distinct shift towards acceptance within the team after being assisted by the scrub nurse during this process, suggesting that the prevailing perception of students as peripheral observers may need to evolve toward recognising them as legitimate peripheral participants [7, 16]. These findings align with established frameworks of professional identity formation [15], which emphasise identity development as a process of socialisation within clinical communities. In this study, students’ sense of belonging, perceived acceptance by the OR team, and clarity of their expected roles strongly shaped how they understood themselves as future physicians. Conversely, unclear expectations, exclusionary interactions, and inconsistent educational practices contributed to uncertainty and discomfort in professional identity development.

Lyon’s study articulates the dynamics between surgeons and students, emphasising how their mutual sizing-up, which is based on trust and legitimacy, can lay the groundwork for positive learning experiences [3]. Our findings suggest that these processes may extend beyond the dyadic relationship between surgeons and students. In our context, interactions with other members of the OR team appeared to shape students’ sense of acceptance and legitimacy, pointing to a more complex set of relational dynamics within the OR. Considering the OR team as part of this broader sizing-up process may help to capture the multifaceted nature of learning in this environment.

In this study, the OR team members reported that it was the first time they had come together to reflect collectively on educational issues, allowing them to recognise problems from each other's perspective. Conflicts among team members should not be overlooked during OR training. When a team engages in open discussion about teaching, it may facilitate problem identification, foster shared educational language, enhance students' acceptance within the team, and ultimately contribute to more meaningful learning experiences. In contrast to the findings of Curry et al. [17], in which students perceived the OR team as operating harmoniously, our study revealed pronounced tensions and interpersonal conflicts during focus group discussions.

Although teamwork is a learning objective in OR training, our findings suggest that students may also be exposed to informal and unintended lessons about interprofessional relationships within the OR. These findings align with previous literature documenting students’ experiences of challenging interactions in surgical settings, often situated within hierarchical structures [1, 9]. Further research is needed to examine the underlying causes and long-term consequences of such interactions, particularly regarding their potential impact on interprofessional collaboration and communication.

The negative attitudes of surgeons towards students have also been described in previous studies [1, 2, 9], but the students in our study stated that surgical educators had been very supportive. This difference may result from our research covering a small group but also from the cultural differences or social effects of declining interest in surgical careers [18].

Concerns related to sterility were articulated most prominently by nurses, whereas this issue was not raised by other members of the OR team. This pattern may reflect nurses’ primary responsibility for maintaining the sterile field, illustrating how professional roles and responsibilities can shape priorities and behaviour patterns in the OR [19].

Our findings are consistent with previous studies that have identified orientation to the OR as an important factor influencing students’ sense of acceptance, anxiety levels, and overall satisfaction with OR-based learning experiences [5–7]. Students in our study expressed a preference for learning materials that could be accessed flexibly, particularly immediately before entering the OR. Several trainers also suggested the development of an e-learning resource to support student orientation. However, further research is needed to determine the most effective approaches to preparing students for the OR setting. Providing flexible, self-paced orientation resources is consistent with Nguyen et al.’s findings, which emphasise the role of student preparedness and initiative in shaping teaching interactions in surgical settings [20]. Similarly, Swanson et al. reported increasing use of digital resources among medical students, reflecting a growing preference for technology-supported learning tools [21]. Taken together, these findings suggest that e-learning–based orientation may represent a feasible approach to supporting students’ preparation for OR-based learning, while allowing flexibility in timing and individual learning needs.

Limitations

Our study has several limitations. Although we opted for focus group discussions with the OR team to gather comprehensive insights and explore internal team dynamics, the group setting may have inhibited some participants from openly critiquing educational practices or communication processes. While individual interviews might have offered a more private forum for candid feedback, demanding schedules of OR team members precluded this additional data collection.

We recruited OR team from departmental representatives on the faculty’s education board. These individuals might be more educationally motivated or more aware of students’ needs than other staff members, which may limit the transferability of our findings to the wider OR workforce and may under-represent more dismissive or unsupportive attitudes. In addition, the use of convenience sampling for student recruitment may have introduced selection bias, as participants who volunteered may have been more motivated or more reflective about their OR experiences than their peers.

While the interviewer (CK) was not directly involved in student supervision during data collection, her previous role as an anaesthesiologist at the institution may have influenced responses. However, consistent themes across student interviews suggest that the feedback reflected broader concerns.

As with all qualitative research, our findings are context-specific and not generalisable. Nonetheless, they provide useful insights for improving undergraduate surgical education.

Finally, while member checking was successfully completed with six student participants, only three members of the OR team were able to participate due to their demanding schedules (two surgeons and an anaesthetist). As a result, student perspectives may have been more extensively validated than those of the OR team, which may have influenced the relative emphasis of viewpoints in the findings. We sought to address this through careful analysis, reflexive consideration of researcher positioning, and triangulation across data sources.

Conclusion

Our study highlights the role of the OR in shaping medical students’ professional development, illustrating how it can offer meaningful learning opportunities within this context. However, without careful attention to the structure and quality of education, the challenges within the OR environment may limit the educational benefits. Students’ accounts suggest how interactions and unclear educational roles can shape learning experiences and perceptions of teamwork.

The contrast between the OR's perceived harmonious functioning and the tensions revealed in our focus groups points to potential gaps in communication and student integration within the OR team. Participants’ accounts suggest that strategies such as structured orientation, formal introductions, clear educational objectives, and recognition of the role of all OR personnel may support student learning.

Participants frequently described the OR as a “sacred” space, reflecting a shared perception among staff that appeared to shape interactions within the team. Future research could explore how staff perceptions of the OR, including its perceived sacredness, influence team dynamics and interactions with newcomers.

Our findings also suggest the value of timely and flexible access to preparatory learning materials. Students strongly preferred resources they could review independently, particularly just before entering the OR. Based on these findings, an e–learning–based orientation module may offer a feasible approach to support students’ preparation for the OR.

In conclusion, enhancing student integration practices and the flexible orientation modules strategies may help align educational goals with the established culture of the OR and support more positive learning experiences.

Authors’ contributions

CK conceived the study, conducted the interviews. BS assisted in the design of the study and supervised the research process. CK and BS performed the qualitative analysis. This study is constitutes part of PhD thesis project titled “Development of an Online Operating Room Orientation Programme for Medical Students” by C. Kanburoglu, conducted at Hacettepe University Institute of Medical Education. The present study represents the exploratory and needs-assessment phase of the doctoral research and informed the subsequent development of the online orientation programme.

Funding

There is no funding associated with the work featured in this article.

Data availability

Due to ethical restrictions and the need to protect participant confidentiality, the data supporting the findings of this study are not publicly available. Anonymised data may be requested from the corresponding author for ethically approved research purposes.

Declarations

Ethics approval and consent to participate

Ethical approval was obtained from the RTE University Ethics Committee (protocol number: 2022/100). Written informed consent was obtained from all participants prior to data collection. This study was conducted in accordance with the principles of the Declaration of Helsinki.

Consent for publication

Not applicable.

Competing interests

Not applicable.