Abstract
Background
Early clinical exposure allows undergraduate medical students to encounter authentic clinical practice, but novice learners may not know what to observe or how to interpret complex clinical events. This challenge is particularly relevant in anesthesiology, where many professional activities are embedded in perioperative workflow and are not immediately visible to beginners. This study examined whether a structured perioperative observation model was associated with improved learning objective clarity and self-reported purposeful observation during early anesthesiology clinical exposure.
Methods
This prospective cluster-randomized educational study included 154 s-year undergraduate medical students from 12 clerkship groups. Six groups were assigned to a conventional lecture–observation–question-and-answer clerkship, and six groups were assigned to a structured perioperative observation model organized according to the Bridge-in, Objectives, Pre-assessment, Participatory learning, Post-assessment, and Summary (BOPPPS) framework. The primary outcome was the post-clerkship score for learning objective clarity and self-reported purposeful observation ability. Secondary outcomes included anesthesia-related awareness, knowledge test scores, post-clerkship learning experience, and open-ended feedback. A linear mixed-effects model was used to account for clerkship group clustering.
Results
Seventy-six students were assigned to the conventional group and 78 to the structured observation group. Academic track distribution differed between groups, while other baseline characteristics were comparable. The structured observation group had a higher primary outcome score than the conventional group (22.55 ± 1.17 vs. 16.74 ± 1.36, P < 0.001). The association remained significant after adjustment for age, sex, academic track, prior operating room exposure, and baseline interest in anesthesiology. The structured group also showed greater gains in anesthesia-related awareness and knowledge and higher post-clerkship learning experience scores. Findings were consistent across academic track and prior operating room exposure strata.
Conclusions
Structured perioperative observation was associated with higher learning objective clarity and self-reported purposeful observation during early anesthesiology clinical exposure. By guiding students to observe perioperative workflow, anesthesiologists’ responsibilities, patient safety, and team collaboration, this model may help novice medical students transform passive clinical exposure into more goal-directed learning.
Supplementary Information
The online version contains supplementary material available at https://doi.org/10.1186/s12909-026-10042-y.
Keywords: Purposeful observation, Early clinical exposure, Workplace-based learning, Anesthesiology, Medical students
Introduction
Early clinical exposure is increasingly emphasized in undergraduate medical education because it allows students to encounter authentic clinical practice before formal clerkship training [1]. However, the educational value of early exposure depends not only on access to clinical environments, but also on whether students are able to identify what is worth observing and how to interpret what they see [2]. For novice learners, real clinical settings may be complex, unfamiliar, and cognitively overwhelming [3]. Without clear objectives and structured guidance, early clinical exposure may become passive watching rather than purposeful learning .
This challenge is particularly relevant in anesthesiology. The perioperative environment is fast-paced, safety-sensitive, and highly regulated, with limited opportunities for direct student participation [4, 5]. At the same time, many essential aspects of anesthesiology practice are not immediately visible to beginners. Students may easily notice anesthesia machines, monitors, drug administration, or induction procedures, but may fail to recognize the broader professional work of anesthesiologists, including preoperative risk assessment, anticipation of airway and hemodynamic instability, interpretation of monitoring information, intraoperative decision-making, recovery assessment, safe handover, and team coordination [6]. Therefore, early anesthesiology exposure requires more than simply bringing students into the operating room or post-anesthesia care unit (PACU); it requires an instructional approach that helps students understand what meaningful observation should involve.
Purposeful observation may be a key learning outcome in early anesthesiology clinical exposure. For undergraduate medical students who have not yet received systematic clinical training, observation itself is a skill that needs to be developed [7]. Students need a framework that helps them enter perioperative settings with clear learning objectives, attend to clinically meaningful events, and connect what they observe with patient safety, workflow, and professional roles [8]. A structured perioperative observation model may provide such scaffolding by translating complex clinical processes into concrete, observable, and reflectable learning tasks.
The Bridge-in, Objectives, Pre-assessment, Participatory learning, Post-assessment, and Summary (BOPPPS) model is a structured, learner-centered instructional framework that may be suitable for this purpose. In a typical BOPPPS framework, the Bridge-in component introduces a clinical context or problem to stimulate students’ interest; Objectives clarify the expected learning outcomes; Pre-assessment identifies learners’ baseline understanding; Participatory learning promotes active engagement during the learning process; Post-assessment evaluates whether learning objectives have been achieved; and Summary reinforces key concepts through feedback and reflection [9]. Previous studies have suggested that BOPPPS-based teaching can improve learner engagement, knowledge acquisition, and learning satisfaction in medical and health professions education [10, 11]. In anesthesia-related education, BOPPPS-based or BOPPPS-integrated approaches have also been explored. For example, a blended teaching model combining BOPPPS with a small private online course (SPOC) has been used for ultrasound-guided spinal anesthesia training among anesthesiology clinicians and was associated with better theoretical performance and shorter procedural time than traditional teaching [12]. More recently, a BOPPPS-simulation model has been reported for crisis training in anesthesia residents, suggesting that the framework may also be adaptable to simulation-based anesthesia training [13]. Nevertheless, evidence remains limited regarding the application of the BOPPPS framework to early anesthesiology clinical exposure, particularly for guiding purposeful observation of perioperative workflow among undergraduate medical students.
In this cluster-randomized study, we examined whether a structured perioperative observation model was associated with improved learning objective clarity and self-reported purposeful observation among undergraduate medical students during early anesthesiology clinical exposure. The primary outcome was the post-clerkship score for learning objective clarity and purposeful observation ability. We hypothesized that structured observation would help students observe anesthesiology practice with clearer objectives and would enhance their awareness of perioperative workflow, anesthesiologists’ responsibilities, patient safety, and learning engagement.
Methods
Study design and participants
This was a prospective cluster-randomized educational study conducted among second-year undergraduate medical students undertaking early clinical exposure in anesthesiology. Participants were recruited from routine anesthesiology clerkship groups arranged according to the institutional teaching schedule. Randomization was performed at the level of pre-existing clerkship groups rather than individual students to reduce potential contamination between students within the same clerkship group. Each group included 10–16 students from clinical medicine, anesthesiology, stomatology, or psychiatry tracks.
A total of 12 clerkship groups were randomly assigned to either the conventional clerkship group or the structured perioperative observation group. Students were eligible if they were assigned to the anesthesiology early clinical exposure program and provided informed consent. Students who did not complete the pre-clerkship questionnaire, post-clerkship questionnaire, or knowledge test were excluded.
The study was approved by the Ethics Committee of The Third Xiangya Hospital of Central South University (Approval No. Kuai 23374). Written informed consent was obtained from all participants. The study did not involve patient treatment, student participation in clinical decision-making, or health-related clinical outcomes; therefore, clinical trial registration was not applicable.
Sample size consideration
No formal a priori sample size calculation was performed before participant enrollment. This study was designed as a pragmatic and exploratory cluster-randomized educational study embedded within the routine anesthesiology early clinical exposure schedule. The number of clusters and participants was determined by the pre-existing clerkship group arrangement during the predefined study period, and all eligible students assigned to the anesthesiology early clinical exposure program during this period were invited to participate. The absence of a formal a priori sample size calculation was acknowledged as a limitation.
Randomization and blinding
The 12 pre-existing clerkship groups were randomly allocated in a 1:1 ratio to the conventional clerkship group or the BOPPPS-based structured perioperative observation group. Because the two teaching models differed visibly in teaching organization, checklist use, instructor guidance, and summary reflection, blinding of students and instructors was not feasible. Questionnaire entry and statistical analyses were performed by researchers who were not involved in the teaching implementation. Because the teaching models were identifiable from the intervention records and questionnaires, complete blinding of the analysts to group allocation was not feasible.
Learning objectives
The general clerkship syllabus and overall educational objectives were the same for both groups. By the end of the clerkship, students were expected to be able to describe the basic workflow of perioperative anesthetic care; identify key components of preoperative anesthesia assessment and risk evaluation; recognize the main steps of anesthesia implementation, intraoperative monitoring and management, recovery assessment, and postoperative handover; understand the anesthesiologist’s role in patient safety, risk prevention, and team collaboration; and reflect on the professional value of anesthesiology in perioperative medicine. In the BOPPPS-based structured observation group, these objectives were explicitly presented before clinical exposure and operationalized into checklist-guided observation tasks.
Educational intervention
Both groups completed the same 180-minute early anesthesiology clinical exposure schedule. The total instructional time, clinical exposure time, clinical settings, opportunities for operating room observation, pre-clerkship safety orientation, and instructor team source were the same for both groups. Each session included 120 min of clinical exposure, consisting of approximately 20 min in the preoperative anesthesia assessment area, 10 min in the surgical waiting area, 60 min in the operating theatre, and 30 min in the post-anesthesia care unit (PACU). The remaining 60 min were organized differently between groups: the conventional group received a 45-minute didactic lecture and a 15-minute group question-and-answer summary, whereas the BOPPPS-based structured observation group received a 20-minute Bridge-in and Objectives session and a 40-minute checklist-based reflection and summary session. Operating theatre observation was conducted in subgroups of two students per operating room. Before entering the clinical areas, all students received standardized orientation on operating room conduct, aseptic requirements, patient privacy, observation boundaries, safety precautions, and clerkship discipline. Before implementation, the teaching team received unified training and collective preparation to standardize the teaching objectives, clinical observation scope, patient safety requirements, and evaluation criteria. Both groups used the same pre-clerkship questionnaire, post-clerkship questionnaire, and basic knowledge test to ensure consistency of educational evaluation. The main differences between groups were the teaching organization, presentation of learning objectives, degree of structure in observation tasks, instructor guidance, and format of post-clerkship summary and reflection.
The conventional clerkship group received a lecture–observation–question-and-answer model. Before clinical exposure, students completed the pre-clerkship questionnaire and basic knowledge test, followed by standardized safety orientation. They then attended an approximately 45-minute didactic lecture covering the anesthesia department workflow, perioperative management, anesthesiologists’ responsibilities, common anesthesia techniques, anesthetic pharmacology, intraoperative monitoring, and general observation points. Students subsequently entered the clinical areas for observation, during which instructors provided real-time explanations according to the surgical and anesthetic process. The clerkship ended with an approximately 15-minute group question-and-answer session and summary.
The structured perioperative observation group received a goal-oriented, checklist-guided, and reflective clerkship model. Before clinical exposure, students completed the pre-clerkship questionnaire and basic knowledge test, followed by standardized safety orientation. Instructors then provided an approximately 20-minute bridge-in and objective session. This session introduced the perioperative anesthesia management workflow, anesthesiologists’responsibilities in preoperative, intraoperative, and postoperative care, patient safety, team collaboration, and patient-centered perioperative management. During the Pre-assessment component, students’ baseline understanding and potential observation difficulties were identified through the pre-clerkship questionnaire, knowledge test, and brief instructor questions. During Participatory learning, students used a perioperative workflow-oriented observation checklist to guide clinical observation. The checklist covered preoperative assessment, surgical entry verification, anesthesia implementation and intraoperative management, PACU recovery, postoperative management, patient safety, and team collaboration. The student version was used to prompt observation and keyword recording, whereas the instructor version was used to standardize teaching prompts, guiding questions, and discussion content. During observation, instructors used the checklist to provide guided explanations, highlight observation priorities, ask brief questions, and connect observed events with clinical context. If the clinical process in a single operating room did not cover all checklist items, instructors supplemented the relevant content during the group discussion. After clinical exposure, students completed the post-clerkship questionnaire, basic knowledge test, and learning experience evaluation. They then participated in a checklist-based Summary session, during which instructors corrected incomplete or inaccurate understanding, reinforced key perioperative concepts, and guided reflection on the anesthesiologist’s role in perioperative workflow, patient safety, risk prevention, handover, and team collaboration. The checklist was used as an observation guide rather than an assessment tool and did not replace the post-clerkship educational evaluation questionnaire. It was not included in outcome scoring. The student and instructor versions of the perioperative workflow-oriented observation checklist are provided in Supplementary Tables S1 and S2. A workflow comparison between the conventional clerkship model and the BOPPPS-based structured perioperative observation model is shown in Fig. 1.
Fig. 1.
Workflow comparison between the conventional group and the BOPPPS-based structured observation group
Development and quality control of educational instruments
The observation checklists, questionnaires, knowledge test, and scoring rubrics were developed by the research team for this study. The questionnaire items were designed based on the learning objectives of early clinical exposure in anesthesiology, the perioperative anesthesia workflow, and patient safety teaching requirements. The observation checklists were developed to translate the perioperative workflow into observable learning tasks for students and standardized guiding prompts for instructors.
The initial materials were reviewed and revised by teachers with experience in anesthesiology clerkship teaching and medical education research to ensure alignment with the teaching objectives, content relevance, clarity, and feasibility. Before formal implementation, the wording of the questionnaires and checklist items was checked and adjusted to ensure that students could correctly understand the intended meaning. Questionnaires were distributed and collected on site. Data organization and entry were performed by researchers who were not involved in the teaching intervention. Internal consistency of the post-clerkship anesthesia-related awareness scale, the post-clerkship learning experience evaluation scale, and the primary outcome domain was evaluated using Cronbach’s α.
Outcome measures
Teaching outcomes were evaluated using pre- and post-clerkship questionnaires, a knowledge test, a post-clerkship learning experience evaluation, and open-ended feedback. The pre- and post-clerkship questionnaires are provided in Supplementary Tables S3 and S4, and the questionnaire domains, correct answers, and scoring rules are provided in Supplementary Table S5.
The primary outcome was the post-clerkship score for learning objective clarity and self-reported purposeful observation ability. Secondary outcomes included anesthesia-related awareness scores, knowledge test scores, other post-clerkship learning experience domains, and open-ended feedback themes.
Anesthesia-related awareness was assessed before and after the clerkship using a self-rated scale covering four domains: perioperative workflow awareness, anesthesiologist responsibility awareness, anesthesia safety and risk awareness, and clinical observation readiness. Items were scored using a 5-point Likert scale, with higher scores indicating higher self-rated awareness.
The knowledge test included 10 items covering preoperative anesthesia assessment, surgical entry verification, intraoperative monitoring, PACU management, patient safety, and anesthesiologists’ responsibilities. Single-choice items were scored as 1 point for a correct answer and 0 points for an incorrect answer. Multiple-choice items were scored as 1 point only when all correct options were selected without incorrect options. Sequence items were scored as 1 point only when the complete sequence was correct. The total score ranged from 0 to 10.
The post-clerkship learning experience evaluation included four domains: learning objective clarity and purposeful observation ability, learning engagement and student–instructor interaction, anesthesiologist role recognition and patient safety awareness, and learning interest and professional value identification. Items were scored using a 5-point Likert scale, with higher scores indicating more positive learning experience. The learning objective clarity and purposeful observation ability domain was prespecified as the primary outcome domain.
Open-ended feedback
Open-ended questions asked students to describe their most impressive clinical observations, new understanding of anesthesiologists’ work, and topics they wished to learn more about. Responses were independently reviewed by two researchers and summarized thematically. Disagreements were resolved through discussion. Open-ended responses were not scored and were not subjected to inferential statistical analysis, as specified in Supplementary Table S5. The open-ended feedback was used to provide descriptive and explanatory information regarding students’ observation focus and learning experience. Implementation records included clerkship completion, questionnaire response validity, completion of the structured observation checklist, and whether any event occurred that affected normal operating room workflow or patient safety.
Statistical analysis
Continuous variables were summarized as mean ± standard deviation or median with interquartile range, and categorical variables as n (%). Between-group comparisons were performed using independent-samples t tests, Mann–Whitney U tests, chi-square tests, or Fisher’s exact tests, as appropriate.
For pre- and post-clerkship outcomes, within-group changes were assessed using paired t tests or Wilcoxon signed-rank tests. Between-group differences in post-clerkship scores and change scores were assessed using independent-samples t tests or Mann–Whitney U tests. Internal consistency was evaluated using Cronbach’s α.
The primary outcome was analyzed using a linear mixed-effects model, with teaching group as a fixed effect and clerkship group as a random effect to account for cluster-level allocation. The adjusted model included age, sex, academic track, prior operating room experience, and baseline interest in anesthesiology as covariates; academic track was entered as a categorical variable.
Stratified analyses of the primary outcome were performed by academic track and prior operating room experience. Academic track was stratified as anesthesiology-track versus non-anesthesiology-track, and prior operating room experience as yes versus no. Interaction terms between teaching group and each stratification variable were tested.
Open-ended feedback was summarized using thematic description and was not subjected to inferential statistical analysis. Secondary outcomes were analyzed as exploratory outcomes and were used to support interpretation of the primary outcome. All tests were two-sided, with P < 0.05 considered statistically significant. Analyses were performed using SPSS software.
All verbal teaching activities and written study materials were conducted in Chinese. Materials reported in English, including checklist content, questionnaire items, scoring rules, and open-ended feedback themes, were translated from Chinese by the authors and checked against the original Chinese version to ensure semantic consistency.
Results
Participants and baseline characteristics
A total of 154 second-year undergraduate medical students from 12 clerkship groups were included. Seventy-six students from 6 clerkship groups were assigned to the conventional clerkship group, and 78 students from 6 clerkship groups were assigned to the structured perioperative observation group. All students completed the pre-clerkship questionnaire, post-clerkship questionnaire, and knowledge test, with a valid response rate of 100%. Students in the BOPPPS-based structured perioperative observation group completed the workflow-oriented observation checklist and group reflection session. No teaching-related event affecting normal operating room workflow or patient safety occurred during implementation.
Baseline characteristics and pre-clerkship assessment scores are shown in Table 1. The two groups were comparable in most baseline variables, including sex, age, prior operating room exposure, prior anesthesiology-related learning experience, baseline interest in anesthesiology, baseline anesthesia-related awareness scores, and baseline knowledge test scores. Academic track distribution differed between groups.
Table 1.
Baseline characteristics and pre-clerkship assessment scores
| Variable | Conventional (n = 76) | Structured (n = 78) | P value |
|---|---|---|---|
| Male, n (%) | 37 (48.7) | 41 (52.6) | 0.747 |
| Age, y | 20.58 ± 1.02 | 20.36 ± 0.77 | 0.134 |
| Academic track, n (%) | 0.043 | ||
| Clinical medicine | 41 (53.9) | 27 (34.6) | |
| Anesthesiology | 10 (13.2) | 15 (19.2) | |
| Stomatology | 11 (14.5) | 23 (29.5) | |
| Psychiatry | 14 (18.4) | 13 (16.7) | |
| Prior operating room exposure, n (%) | 7 (9.2) | 12 (15.4) | 0.328 |
| Prior anesthesia learning, n (%) | 16 (21.1) | 17 (21.8) | 1.000 |
| Personal/family anesthesia experience, n (%) | 0.882 | ||
| Yes | 17 (22.4) | 15 (19.2) | |
| No | 41 (53.9) | 43 (55.1) | |
| Unknown | 18 (23.7) | 20 (25.6) | |
| Baseline interest | 3.14 ± 0.80 | 3.17 ± 0.86 | 0.870 |
| Workflow awareness | 6.53 ± 1.18 | 6.53 ± 1.16 | 0.997 |
| Role awareness | 8.86 ± 1.40 | 8.90 ± 1.58 | 0.861 |
| Safety/risk awareness | 4.36 ± 0.92 | 4.36 ± 0.77 | 0.978 |
| Observation readiness | 1.96 ± 0.58 | 2.04 ± 0.67 | 0.442 |
| Total awareness | 21.70 ± 2.36 | 21.82 ± 2.59 | 0.758 |
| Knowledge score | 4.49 ± 1.17 | 4.53 ± 1.38 | 0.851 |
Data are presented as mean ± SD or n (%)
Scale reliability
The post-clerkship anesthesia-related awareness scale showed good internal consistency, with an overall Cronbach’s α of 0.884. The post-clerkship learning experience evaluation also showed good internal consistency, with an overall Cronbach’s α of 0.913. The Cronbach’s α for the learning objective clarity and self-reported purposeful observation domain was 0.845.
Primary outcome and learning experience
Post-clerkship learning experience scores are shown in Table 2. The structured perioperative observation group had a higher score for the primary outcome, learning objective clarity and self-reported purposeful observation, than the conventional clerkship group. The structured perioperative observation group also had higher scores in the other learning experience domains and in the total learning experience score.
Table 2.
Post-clerkship learning experience evaluation
| Variable | Conventional (n = 76) |
Structured (n = 78) |
t value | P value |
|---|---|---|---|---|
| Learning objective clarity and self-reported purposeful observation | 16.74 ± 1.36 | 22.55 ± 1.17 | -28.471 | < 0.001 |
| Engagement / interaction | 17.36 ± 1.42 | 21.50 ± 1.56 | -17.222 | < 0.001 |
| Role recognition / patient safety | 21.87 ± 1.41 | 26.90 ± 1.42 | -22.068 | < 0.001 |
| Interest / professional value | 14.87 ± 1.44 | 17.26 ± 1.07 | -11.704 | < 0.001 |
| Total score | 70.83 ± 2.81 | 88.21 ± 2.45 | -40.950 | < 0.001 |
Data are presented as mean ± SD. The learning objective clarity and self-reported purposeful observation domain was prespecified as the primary outcome
Mixed-effects model for the primary outcome
The linear mixed-effects model results are shown in Table 3. Structured perioperative observation was associated with a higher primary outcome score in both the unadjusted and adjusted models.
Table 3.
Mixed-effects model for the primary outcome
| Model | Effect estimate | 95% CI | P value |
|---|---|---|---|
| Unadjusted model | β = 5.81 | 5.41 to 6.22 | < 0.001 |
| Adjusted model | β = 5.89 | 5.47 to 6.31 | < 0.001 |
Outcome: learning objective clarity and self-reported purposeful observation ability. Teaching group was included as a fixed effect, and clerkship group was included as a random effect. The adjusted model included age, sex, academic track, prior operating room exposure, and baseline interest in anesthesiology as covariates
CI confidence interval
Awareness and knowledge outcomes
Pre- and post-clerkship anesthesia-related awareness and knowledge scores are shown in Table 4. Both groups showed increases in anesthesia-related awareness scores and knowledge test scores after the clerkship. The increases in awareness domains and knowledge score were greater in the structured perioperative observation group than in the conventional clerkship group.
Table 4.
Pre- and post-clerkship awareness and knowledge changes
| Variable | Conventional pre | Conventional post | Δ Conventional | Structured pre | Structured post | Δ Structured | P for Δ |
|---|---|---|---|---|---|---|---|
| Workflow awareness | 6.53 ± 1.18 | 9.76 ± 1.50 | 3.24 ± 1.08 | 6.53 ± 1.16 | 13.56 ± 0.99 | 7.04 ± 0.89 | < 0.001 |
| Role awareness | 8.86 ± 1.40 | 13.21 ± 1.96 | 4.36 ± 1.25 | 8.90 ± 1.58 | 17.46 ± 1.31 | 8.56 ± 1.17 | < 0.001 |
| Safety/risk awareness | 4.36 ± 0.92 | 6.29 ± 1.20 | 1.93 ± 0.85 | 4.36 ± 0.77 | 9.05 ± 0.82 | 4.69 ± 0.74 | < 0.001 |
| Observation readiness | 1.96 ± 0.58 | 3.39 ± 1.01 | 1.43 ± 0.79 | 2.04 ± 0.67 | 4.44 ± 0.59 | 2.40 ± 0.65 | < 0.001 |
| Total awareness | 21.70 ± 2.36 | 32.66 ± 3.52 | 10.96 ± 2.32 | 21.82 ± 2.59 | 44.51 ± 2.35 | 22.69 ± 1.52 | < 0.001 |
| Knowledge score | 4.49 ± 1.17 | 6.84 ± 1.31 | 2.36 ± 0.81 | 4.53 ± 1.38 | 8.06 ± 1.42 | 3.54 ± 0.80 | < 0.001 |
Data are presented as mean ± SD. Δ indicates post-clerkship score minus pre-clerkship score. P values compare change scores between groups
Stratified analyses
Stratified analyses of the primary outcome are shown in Table 5. The structured perioperative observation group had higher primary outcome scores than the conventional clerkship group in both academic track strata and in both prior operating room exposure strata. No significant interactions were observed.
Table 5.
Stratified analyses of the primary outcome
| Stratification variable | Stratum | Conventional n | Conventional score | Structured n | Structured score | P value | P for interaction |
|---|---|---|---|---|---|---|---|
| Academic track | Anesthesiology | 10 | 16.70 ± 1.83 | 15 | 22.60 ± 1.30 | < 0.001 | 0.649 |
| Academic track | Non-anesthesiology | 66 | 16.74 ± 1.29 | 63 | 22.54 ± 1.15 | < 0.001 | |
| Prior operating room exposure | Yes | 7 | 16.86 ± 1.46 | 12 | 22.83 ± 1.03 | < 0.001 | 0.798 |
| Prior operating room exposure | No | 69 | 16.72 ± 1.36 | 66 | 22.50 ± 1.19 | < 0.001 |
Outcome: learning objective clarity and self-reported purposeful observation ability. Data are presented as mean ± SD unless otherwise indicated
Open-ended feedback
Open-ended feedback themes are summarized in Table 6. Students in the conventional clerkship group more often described the operating room environment, anesthesia equipment, anesthesia induction, drug administration, and vital sign monitoring. Open-ended feedback suggested that students in the structured perioperative observation group tended to describe perioperative workflow, preoperative risk assessment, surgical entry verification, intraoperative management, PACU recovery, patient safety measures, handover, and team collaboration.
Table 6.
Open-ended feedback themes
| Theme | Conventional group | Structured group |
|---|---|---|
| Environment/equipment | Operating room, machines, monitors | Mentioned less often |
| Anesthesia procedures | Induction, drugs, monitoring | Linked to workflow |
| Perioperative workflow | Isolated observations | Assessment, verification, management, PACU |
| Anesthesiologist role | Drugs and monitoring | Risk assessment, management, transfer |
| Patient safety | Mentioned less often | Checks, monitoring, risk prevention, handover |
| Team collaboration | Mentioned less often | Anesthesiologists, surgeons, nurses |
Themes are presented descriptively and were not subjected to formal statistical comparison
Discussion
In this cluster-randomized educational study, a BOPPPS-based structured perioperative observation model was associated with higher learning objective clarity and self-reported purposeful observation among undergraduate medical students during early anesthesiology clinical exposure. Students in the structured perioperative observation group also showed greater gains in anesthesia-related awareness and knowledge and reported more positive learning experiences. These findings were consistent across academic track and prior operating room experience. Open-ended feedback further showed that students in the conventional group tended to describe visible equipment and procedures, whereas students in the structured observation group more often described perioperative workflow, risk assessment, patient safety, handover, and team collaboration.
The main finding of this study is that structured observation may help novice learners make better use of early anesthesiology exposure. Early clinical exposure is widely used to introduce students to authentic clinical settings, but clinical exposure alone may not be sufficient for meaningful learning [14, 15]. Students who have not yet received systematic clinical training may enter the operating room or PACU without knowing which events are educationally meaningful or how to interpret what they observe [16]. In such circumstances, observation may remain superficial and fragmented. By clarifying learning objectives and providing a workflow-oriented observation checklist, the structured model offered students a practical framework for organizing their attention around specific perioperative tasks and professional roles. This may explain the higher score for learning objective clarity and self-reported purposeful observation in the structured observation group.
This finding may also be interpreted from the perspective of cognitive load and educational scaffolding. For second-year undergraduate medical students, the perioperative environment is highly complex, information-dense, and unfamiliar [17, 18]. Students need to process patient conditions, monitoring data, equipment, anesthesia procedures, surgical workflow, safety checks, and interprofessional communication within a short period of exposure. Without explicit objectives and an observation framework, their limited cognitive resources may be occupied by visually salient but fragmented information, which may increase extraneous cognitive load and reduce the efficiency of learning [19, 20]. The BOPPPS-based structured observation model may have served as an educational scaffold by making key learning tasks explicit before clinical exposure and by converting complex perioperative processes into observable and reflectable components. In this way, students were guided to focus not only on what was visible, but also on why each perioperative step mattered for patient safety and anesthetic management.
The anesthesiology setting is particularly suitable for developing purposeful observation because many core elements of anesthesiology practice are not immediately visible to beginners [21, 22]. Students can easily notice anesthesia machines, monitors, drug administration, and induction procedures. However, the broader work of anesthesiologists includes preoperative evaluation, risk anticipation, airway and hemodynamic management, interpretation of monitoring data, intraoperative decision-making, recovery assessment, safe handover, and coordination with surgical and nursing teams [23]. Without structured guidance, novice students may focus mainly on visible technical elements and overlook these less visible but essential aspects of perioperative care [24]. The open-ended feedback was consistent with this pattern: students in the structured observation group more frequently described workflow, safety checks, PACU recovery, handover, and team collaboration. This suggests that structured observation may influence not only students’ perceived learning experience, but also the focus and depth of their clinical observation.
The differences in open-ended feedback are educationally meaningful. Compared with students in the conventional group, students in the structured observation group appeared more likely to move from “seeing anesthesia procedures” to “understanding anesthesia management”. Their feedback more frequently involved perioperative workflow, preoperative risk assessment, surgical entry verification, dynamic intraoperative management, PACU recovery, patient safety, handover, and team collaboration. These elements are central to the anesthesiologist’s professional role but may be difficult for novice learners to recognize through unstructured observation [25]. The checklist and instructor prompts may therefore have helped students make visible the hidden cognitive and safety work of anesthesiologists, including anticipation of risk, prevention of adverse events, coordination with other team members, and safe transition of care.
The greater gains in anesthesia-related awareness and knowledge further support the value of organizing early clinical exposure around the perioperative workflow. Anesthesiology is not a single procedural encounter but a continuous process involving preoperative assessment, intraoperative management, postoperative recovery, and safe transition of care [26]. For novice learners, this continuity may be difficult to recognize during a short clerkship [27]. A workflow-oriented checklist may help students connect separate clinical scenes into a coherent perioperative management framework [28]. In this study, the structured observation group showed greater improvements in workflow awareness, anesthesiologist responsibility awareness, anesthesia safety and risk awareness, clinical observation readiness, and knowledge test scores. These findings suggest that structured observation may support both students’ self-rated awareness and basic knowledge acquisition during early clinical exposure.
Another relevant finding is that the association between structured perioperative observation and the primary outcome was consistent across academic track and prior operating room experience. Although academic track distribution differed between groups at baseline, the association remained significant after adjustment for academic track and other covariates. In stratified analyses, higher primary outcome scores were observed among both anesthesiology-track and non-anesthesiology-track students. This finding is reasonable because anesthesiology-track students at this stage were still early undergraduate learners and may not yet have developed a systematic framework for clinical observation. Similarly, the findings were consistent among students with and without prior operating room exposure. These results suggest that structured perioperative observation may be applicable to a broad range of early medical learners, rather than only to students with a specific academic background or prior exposure.
From an educational perspective, this study reframes early anesthesiology exposure as a process of developing observation ability rather than simply increasing clinical contact [29]. The structured model did not extend clerkship duration or increase students’ direct participation in clinical procedures. Instead, it reorganized the existing clerkship by reducing passive didactic time and adding explicit objectives, checklist-guided observation, instructor prompts, and summary reflection [30]. This design may be particularly relevant for high-safety clinical environments, where student participation must be limited and teaching activities cannot interfere with clinical workflow. In such settings, improving the quality of observation may be a feasible approach to enhancing the educational value of early clinical exposure.
The BOPPPS framework provided the instructional structure for the intervention, but the educational target of this study was purposeful observation [31]. The Bridge-in and Objectives components clarified what students should focus on before entering the clinical environment. The Pre-assessment component helped identify baseline awareness and potential observation difficulties. Participatory learning was implemented through workflow-oriented observation and instructor prompts, while the Post-assessment and Summary components allowed students to review, organize, and reflect on their observations [32]. Therefore, BOPPPS was not used merely as a general teaching format, but as a structure for guiding novice learners through a complex perioperative environment. This distinction is important because the main contribution of the present model lies in translating complex clinical workflow into observable and reflectable learning tasks.
The timing of this clerkship should also be considered when interpreting the findings. The participants were second-year undergraduate medical students enrolled in an early clinical exposure curriculum [33]. The aim of this clerkship was not to train students to make anesthetic decisions or perform anesthesia procedures, but to help them develop an initial understanding of perioperative workflow, patient safety, and the professional role of anesthesiologists. Because students at this stage usually have limited prior training in pharmacology, pathophysiology, diagnostics, and clinical decision-making, the perioperative environment may impose a high cognitive burden [34]. The structured observation model may therefore be particularly useful in this context because it provides explicit learning goals, observation tasks, instructor prompts, and reflective summary to help students build an initial cognitive framework for later learning.
Limitations
This study has several limitations. First, it was conducted at a single institution, and the findings may be influenced by the local curriculum, teaching culture, and perioperative learning environment. Although students from several academic tracks were included, further studies in different institutions and teaching settings are needed to examine generalizability. Second, no formal a priori sample size calculation was performed because this was a pragmatic exploratory educational study embedded within a fixed clerkship schedule. The number of clusters and participants was determined by the existing teaching arrangement, which may limit the precision of effect estimates. Third, because randomization was performed at the clerkship-group level rather than at the individual-student level to reduce contamination, imbalance in academic track distribution occurred at baseline. We adjusted for academic track in the mixed-effects model and conducted stratified analyses, but residual confounding cannot be completely excluded. Fourth, the observation checklists, questionnaires, and scoring rubrics were developed for the local educational context. Although the materials were reviewed by experienced teachers and the main domains showed acceptable internal consistency, they have not undergone external validation. Finally, because of the visible nature of the educational intervention, students and instructors could not be blinded. In addition, the primary outcome was based on students’ self-reported learning objective clarity and purposeful observation rather than direct behavioral assessment, although the knowledge test and open-ended feedback provided complementary information. This study assessed immediate post-clerkship outcomes only; whether the observed improvements can be sustained or translated into later clinical performance requires further investigation.
Conclusions
In conclusion, structured perioperative observation was associated with higher learning objective clarity and self-reported purposeful observation during early anesthesiology clinical exposure among undergraduate medical students. The model was also associated with greater gains in anesthesia-related awareness and knowledge and more positive learning experience. These findings were consistent across academic track and prior operating room experience. By guiding students to observe perioperative workflow, anesthesiologists’ responsibilities, patient safety, and team collaboration, structured observation may help transform early anesthesiology exposure from passive watching into more purposeful clinical learning.
Supplementary Information
Acknowledgements
The authors thank the undergraduate medical students who participated in this study and the clinical teachers and staff of the Department of Anesthesiology, The Third Xiangya Hospital of Central South University, for their support during the implementation of the clerkship. The authors also thank the teaching administration staff of the Third Clinical Medical College of Central South University for their assistance with clerkship coordination.
Clinical trial number
Not applicable.
Use of artificial intelligence
During manuscript revision, ChatGPT was used only to check grammar and improve language clarity. No artificial intelligence tool was used for study design, data collection, data analysis, result interpretation, or generation of scientific conclusions. All AI-assisted language changes were reviewed and approved by the authors, who take full responsibility for the content of the manuscript.
Authors’ contributions
X.C.Z. designed the study, coordinated the teaching implementation, collected the data, and drafted the manuscript. A.L.T. contributed to study design, teaching implementation, data interpretation, and manuscript revision. M.L.C. performed questionnaire entry and statistical analyses, checked data consistency, contributed to language revision, and reviewed the final manuscript. H.C. conceived and supervised the study, provided overall guidance for the educational design, interpreted the data, and critically revised the manuscript. All authors read and approved the final manuscript.
Funding
No funding was received for this study.
Data availability
No datasets were generated or analysed during the current study.
Declarations
Ethics approval and consent to participate
This study was approved by the Ethics Committee of The Third Xiangya Hospital of Central South University (Approval No. Kuai 23374). All methods were performed in accordance with relevant guidelines and regulations. Written informed consent was obtained from all participants before participation. Participation was voluntary, and students’ responses were anonymized and used only for educational research purposes.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
No datasets were generated or analysed during the current study.