nursing research topics in operating theatre

Learning and Teaching in the Operating Theatre: Expert Commentary from the Nursing Perspective

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• Rachel Cardwell 5 ,
• Emmalee Weston 6 &
• Jenny Davis 7  

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The operating theatre environment is dynamic, fast-paced, and challenging. Increasing complexity in modern surgical techniques and advancing technology means that patients require more intensive nursing care and interventions. Safe and effective surgical care relies heavily on the highly specialized skills and experience of operating theatre nurses who function as part of multidisciplinary teams. Nursing roles in the perioperative environment are diverse and highly specialized and continue to expand. This nursing workforce is however challenged by shortages and recruitment impacted by declining exposure of undergraduate nurses to this specialty area of practice. This chapter discusses learning and teaching in this unique clinical environment and begins with an introduction to the setting and roles of the operative team. It then discusses the challenges and approaches to learning and teaching in this specialist area of nursing practice.

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Cardwell, R., Weston, E., Davis, J. (2021). Learning and Teaching in the Operating Theatre: Expert Commentary from the Nursing Perspective. In: Nestel, D., Reedy, G., McKenna, L., Gough, S. (eds) Clinical Education for the Health Professions. Springer, Singapore. https://doi.org/10.1007/978-981-13-6106-7_66-1

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DOI : https://doi.org/10.1007/978-981-13-6106-7_66-1

Received : 14 October 2020

Accepted : 10 June 2021

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Surgical incidents and their impact on operating theatre staff: qualitative study

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N Serou, S P Slight, A K Husband, S P Forrest, R D Slight, Surgical incidents and their impact on operating theatre staff: qualitative study, BJS Open , Volume 5, Issue 2, March 2021, zraa007, https://doi.org/10.1093/bjsopen/zraa007

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Surgical incidents can have significant effects on both patients and health professionals, including emotional distress and depression. The aim of this study was to explore the personal and professional impacts of surgical incidents on operating theatre staff.

Face-to-face semistructured interviews were conducted with a range of different healthcare professionals working in operating theatres, including surgeons and anaesthetists, operating department practitioners, and theatre nurses, and across different surgical specialties at five different hospitals. All interviews were audio recorded, transcribed verbatim, and analysed using an inductive thematic approach, which involved reading and re-reading the transcripts, assigning preliminary codes, and searching for patterns and themes within the codes, with the aid of NVivo 12 software. These emerging themes were discussed with the wider research team to gain their input.

Some 45 interviews were conducted, generally lasting between 30 and 75 min. Three overarching themes emerged: personal and professional impact; impact of the investigation process; and positive consequences or impact. Participants recalled experiencing negative emotions following surgical incidents that depended on the severity of the incident, patient outcomes, and the support that staff received. A culture of blame, inadequate support, and lack of a clear and transparent investigative process appeared to worsen impact.

The study indicated that more support is needed for operating theatre staff involved in surgical incidents. Greater transparency and better information during the investigation of such incidents for staff are still needed.

Los incidentes quirúrgicos pueden tener efectos significativos tanto en los pacientes como en los profesionales de la salud, entre los que se incluyen el trastorno emocional y la depresión. El objetivo de este estudio fue explorar los efectos personales y profesionales de los incidentes quirúrgicos en el personal del quirófano.

Se llevaron a cabo entrevistas semiestructuradas, cara a cara, a cirujanos y anestesistas, técnicos ( operating department practitioners , ODP) y enfermeras de quirófano de varias especialidades quirúrgicas en cinco hospitales diferentes. Todas las entrevistas se grabaron en audio, se transcribieron textualmente y se valoraron mediante un análisis temático inductivo, que implicó leer y releer las transcripciones, asignar códigos preliminares, y buscar patrones y temas en cada código, todo ello con la ayuda del programa NVivo v12. Los temas que surgieron se discutieron con un equipo de investigación ampliado para conocer sus comentarios.

Se llevaron a cabo 45 entrevistas que duraron generalmente entre 30 y 75 minutos. Se detectaron tras temas principales: el impacto personal y profesional; el impacto del proceso de investigación; y las consecuencias positivas. Los participantes recordaron haber experimentado emociones negativas después de incidentes quirúrgicos que dependían de la gravedad del incidente, del resultado en el paciente y del apoyo recibido por parte de los profesionales de plantilla. Una cultura de culpa, el recibir un apoyo inapropiado y la falta de un proceso de investigación claro y transparente pareció empeorar los resultados.

Este estudio indica que el personal de quirófano involucrado en incidentes quirúrgicos precisa más apoyo. Durante la investigación de este tipo de incidentes aún sigue siendo necesaria una mayor transparencia y proporcionar una mejor información al personal.

Medical errors are thought to affect around 16 per cent of patients admitted to hospital, with 50 per cent of these occurring during surgical procedures 1 , 2 . A ‘surgical incident’ can occur during a surgical or invasive procedure, and may result in patient harm. A recent assessment of the problem in the UK National Health Service (NHS) identified 314 reported surgical incidents in the interval between April 2019 and December 2019, with 165 due to wrong-site surgery, 91 a retained foreign object, and 58 a consequence of wrong implant/prosthesis 3 .

Health professionals have been recognized as secondary victims of medical errors 4 , 5 , defined as ‘a health care provider involved in an unanticipated adverse patient event, medical error and/or a patient related-injury, who becomes victimized in the sense that the provider is traumatized by the event’ 5 , 6 . Studies 7 , 8 have highlighted that, following a surgical incident, surgeons, theatre nurses, and other health professionals can experience emotional distress and depression, with symptoms similar to those of post-traumatic stress syndrome. A survey of 7900 surgeons indicated that, following their involvement in a surgical incident, they experienced low quality of life, anxiety, burnout, and depression in the following 3 months 5 , 6 Such experiences not only affect surgeons and their families, but can also have an adverse impact on the provision of care, clinical performance, and patient safety 4 , 5 . These surgical incidents can have enduring effects and, in some instances, the individuals may never fully recover and may consider changing profession 7 , 9–11 . Some studies indicate that an adverse event can lead to increase in use of illicit drugs 9 , addiction to alcohol, decrease in quality of life, depression, and burnout 12 , 13 .

A systematic review 14 to investigate the impact surgical incidents can have on operating theatre staff highlighted how little had been published on the impact of surgical incidents on the wider operating team beyond surgeons and anaesthetists, or how surgeons and other a health professionals might change their behaviours following a surgical incident.

The main aim of this qualitative study was to explore the psychological, emotional, and behavioural impact of surgical incidents on all operating theatre staff, and how their attitudes or behaviours might change following such events.

The study was classified as a service evaluation by a University Ethics Committee and Health Research Authority, and registered as such within the organization (research site) concerned (IRAS ID: 237980/1158905/37/907). This study was conducted at five teaching hospital sites within one large NHS Trust that provides multispecialty surgical procedures including emergency and major trauma. A recruitment pack including an invitation letter and information sheet was e-mailed to all theatre staff (medical and non-medical) working across the five hospital sites, asking them if they would be willing to participate in the research study. A range of healthcare professionals working within operating theatres (surgeons, anaesthetists, theatre nurses, operating department practitioners (ODPs), and theatre support workers) were approached and asked if they would like to participate in this study. Purposeful sampling was employed to recruit relevant health professionals working in operating theatres with varied experiences across the five hospitals. Some 129 operating theatre staff were identified through investigation records as being involved in a surgical incident and were all contacted by e-mail. The snowball sampling technique was also used to identify potential participants. Posters promoting the study were displayed on Trust noticeboards and in rest rooms. A summary of the study was also presented to medical and non-medical staff who attended any one of 4 different audit days, and three quality and safety meetings attended by staff working in different specialties, and a broad range of other staff, including patient safety advisors and managers involved in risk management and incident investigations, between March and November 2018. A summary of the study was also presented to the Trust’s Safer Surgery Committee and Trust’s Safety Culture Committee, chaired by the Trust Board of Directors, encouraging them to both promote and participate in the study. Health professionals were given the opportunity to ask the researcher questions about the study before participating.

All face-to-face interviews took place at a convenient time and location for the interviewee, and without any other individual present. A standard interview topic guide was used to help guide the interview (available on request). Questions in the topic guide were informed by a literature review, and consultation with patient safety and qualitative research experts. The interview schedule was piloted with four experienced theatre nurses for face validity, and included general questions on the possible causes of surgical incidents, the effects these incidents had on the participant, strategies they used to cope with the incident, any change in attitude and behaviour following the event, and their perspectives of the culture of learning from incidents at both an organizational and individual level, and relevant prompts. All interviews were conducted by a single researcher, audio recorded, transcribed verbatim, and analysed using a reflexive inductive thematic approach 15 with the aid of NVivo 12 (QSR International, Melbourne, Victoria, Australia) 16 , 17 . Saturation was achieved when the themes suggested by interviewees from different professional groups began to repeat themselves, and subsequent participants from the different professional group interviews yielded no major new insights. The researcher used a reflexive thematic approach by familiarity with the data through reading and re-reading the transcripts, and assigning preliminary codes to the interviews transcribed. The researcher also began to identify themes within each transcript (content analysis) 16 , 17 . Consideration was given throughout this process to the study objectives, and the identified themes of emotional and behavioural impact of surgical incidents on operating theatre staff, and how their attitudes or behaviours might change after such events. The researcher then generated an index or conceptual framework by which the raw data could be labelled and sorted. This involved identifying recurring themes and concepts, together with the terms used in the interview schedule and wider literature. A workable list of main themes and subthemes was compiled and applied systematically to the whole data set. The researcher interpreted the data and assigned a description to them. Patterns were investigated and relationships between all levels (such as personal and professional impact and nature of the incident) were noted. The researcher also began to build explanations for the recurring patterns and associations in the data. This process involved interrogating the data set as a whole to identify linkages between sets of phenomena and exploring why such linkages occurred. These linkages were displayed on a series of maps to further improve understanding and clarity.

Throughout the analysis, four other researchers independently coded a selection of interview transcripts, and compared and discussed these codes in depth with the initial researcher to reduce researcher bias. Themes or trends generated from each step of the data analysis, or any sections of data that did not support generating themes, were also discussed with the other researchers to uncover bias.

Some 45 face-to-face interviews were conducted between February 2018 and December 2018, each lasting between 30 and 75 min. Participants included eight surgeons, eight anaesthetists, 12 theatre scrub nurses, nine ODPs and eight healthcare assistants from different surgical specialties across five hospital sites ( Table 1 ). All participants described incidents that could be considered moderate in severitythere was moderate increase in treatment following surgery.

Details of study participants

ODP, operating department practitioner.

Personal and professional impact

Most of the theatre staff interviewed (36 of 45) felt that surgical incidents had both a personal and professional impact on them. One member of the junior theatre staff described how it had a ‘very big impact on personal life and on professional life’, influencing the way she worked and work-related decision-making. An ODP questioned her ability to do her job, leading to a sense of low esteem, whereas another theatre staff member described how it ‘made me doubt in my abilities to be a scrub nurse, to count, to see with my eyes, to trust what my eyes are seeing’.

Some 32 participants described short- or long-lived negative emotional impacts. In the short term, these included loss of confidence, personal life interference (social impact), anger, anxiety, sadness, worrying about their job and career progression, sickness, and depression. In the long term, negative impacts included losing trust and confidence in other health professionals, and being overcautious or risk-averse in clinical practice. The latter sometimes led to confusion and misinterpretation within the team. One general surgery consultant described feeling sad about surgical incidents that had happened in the past and having to deal with it in his own way. A vascular theatre nurse described how recalling a past incident evoked an emotion of anger and frustration: ‘ Last year a patient was anaesthetized and is on the operating table and all of a sudden during the ‘time-out’ phase of the Surgical Safety Checklist we realized that the patient did not sign the consent form. Surgery was cancelled and the patient was rescheduled. It is a massive surgical incident due to negligence from the team as no one checked the patient consent form before putting her to sleep. It really infuriated me; I was really mad on that day and even now’.

It was noted how the same or similar surgical incidents could occur more than once. One consultant anaesthetist explained that ‘we can accept that it [surgical incident] is a one-off and we aim to learn from the incident. If the same incident happens again in a month and again in two months’ time, then it is very depressing’. A theatre support worker described the range of emotions experienced when a cancer specimen was lost, including guilt, sadness, anger, and rage. The same participant felt that staff were reluctant to admit responsibility owing, in part, to a perceived blame culture.

One anaesthetic trainee recalled how the impact of surgical incidents experienced by theatre staff might be related to the associated risks of the procedure. She gave two examples: one high-risk patient who died during a procedure; ‘even though the death in theatres was termed as a surgical incident, my emotional reaction was less negative as we did everything for the patient’. In a second incident , the patient had been given a regional block on the wrong side of his leg before surgery. The operation was performed, and the patient had severe postoperative complications; ‘I was devastated, speechless and the negative emotions I had at that time were severe because it should have not happened’.

Impact of the investigation process

The majority of participants (32 of 45) highlighted a lack of transparency in how the investigative process was conducted following surgical incidents. One junior member of theatre staff explained how she was ‘not asked to do anything, not scrub, not even for simple cases’ and worried about the long-term implications for her future. Another explained how she ‘did not know what was going on’ during the investigative process, with ‘the most stressful bit being because there’s a belief around that the surgeons will always try and wriggle themselves out of it and then lay the blame on the scrub staff or on the theatre staff’.

Positive consequences

Despite the overwhelmingly negative experiences of surgical incidents, several participants emphasized how surgical incidents had a positive impact on their career and professional development. They highlighted the importance of attentiveness and cautious practice, with one junior ODP recalling: ‘I took a positive spin on it [surgical incident] of being more cautious the next time, over checking and being more thorough in my checks and I think it had a positive effect on my overall ability to perform’. One senior anaesthetic nurse explained how it had a positive long-term impact on their professional practice and theatre practices in general: ‘professionally it developed me as a practitioner, which I am now, out of that adversity it made me cautious, and from early point of my career, I was able to measure what was expected of me’.

This qualitative study explored the second-victim phenomenon with regard to healthcare professionals, especially those working in operating theatres, in the setting of the UK NHS. This study identified the profound impact of surgical incidents on medical and non-medical operating theatre staff. Consistent with previous research, participants predominantly recalled negative emotions, irrespective of their profession and years of experience 5 , 11 , 18–22 . These negative emotions could be mapped to earlier studies describing six stages to recovery for second victims 23 , with most participants in the present study experiencing immediate chaos and confusion after the surgical incident, followed by re-evaluation in isolation, seeking support, worrying about restoring personal and professional integrity, and finally moving on or surviving the surgical incident, but constantly being beleaguered by it ( Table 2 ). The majority of participants described the overall impact as long-lasting.

Examples from study mapped to six stages to recovery of Scott and colleagues 23 for second victims

This study found little difference between the impact that medical and non-medical theatre staff experienced following a surgical incident. Similar to previous studies 7 , 9 , 10 , 24 , most participants emphasized that the surgical incidents affected them both personally and professionally. The severity of the negative emotions experienced appeared to depend on the nature and severity of the incident, patient outcomes, causative factors, support received, and the investigative process. Participants felt that the negative impact was very profound after what was perceived to be a preventable or avoidable surgical incident, compared with those that were perceived as non-preventable or inevitable.

The present study found that operating theatre staff were affected both by the incident itself and by the manner in which the incident was handled, as noted elsewhere 20 , 21 , 25 . A culture of blame, inadequate support, and a lack of a clear and transparent investigation seemed to deepen and extend the impact of the original incident. Clinician-led reviews created suspicion among those being investigated, leading staff to question how much information they should disclose. Most participants commented on inadequate organizational support and, when support was received, that it was often chaotic. This study suggests that more support needs to be offered during the investigative process, and in an organized fashion, to operating theatre staff involved in surgical incidents.

Medical errors cause patient harm primarily owing to human or systemic factors 2 , 10 , 26–28 . There is a risk of human error behind every endeavour, but health professionals should be held accountable only for things under their control. Following patient safety incidents, the current practice in NHS organizations often includes system improvements, such as change of policy or clinical practice based on ‘one size fits all’ 26 , 27 , 29 . Researchers from improvement science propose complex adaptive theory, which requires the NHS hierarchy to move away from standard responses to patient safety incidents, and instead reflect on the complexity of the healthcare system and how to support clinical staff adequately 29 . The complex nature of everyday clinical work still needs to be acknowledged correctly, and that far more things get done correctly than wrongly 26 , 27 , 29 .

The importance of promoting just culture in organizations following incidents has been emphasized elsewhere 30–33 , including guidelines for NHS leaders and managers 34 . The aviation industry and military employ trained human factors experts to support organizations, managers, and staff during the investigative and learning process following safety incidents 35–38 . More work needs be to done by healthcare organizations to explore how these roles could be adopted to promote effective investigation and safe learning systems. Multidisciplinary team input to review or investigate the incidents, to improve shared learning and emphasize the importance of safety, has been suggested as a reasonable approach 27 , 39 , 40 .

Some participants in the study highlighted the positive impact that the surgical incidents had on them, which was primarily dependent on the support they received, a finding widely highlighted in previous research 4 , 5 . Resilience and adaptability are considered key to the sustainability of the workforce in complex healthcare system such as the NHS 29 , 41 .

Several institutions in the USA and Europe have developed formal second-victim support programmes that allow health professionals to cope with their emotional distress by obtaining timely support in an empathetic, confidential, non-judgemental environment 4 , 6 , 42 . The Resilience in Stressful Events (RISE) programme is a multidisciplinary second-victim work programme initiated by John Hopkins University, which supports healthcare workers who were involved in a patient safety incident 42 . Research needs to be conducted to explore how these supporting structures could be adapted for use in the NHS. A list of potential recommendations is shown in Table 3 .

Potential recommendations from study

NHS, National Health Service.

This study has a number of limitations. It was confined to staff working in either the anaesthetic room or operating theatre. Staff working in preassessment and postanaesthetic care or recovery units, who can be considered part of the surgical team, were excluded. There is a risk of self-selection bias, as health professionals chose whether or not to participate in this study, although participants varied in profession, sex, and years in practice. The extent to which the findings can be generalized across the NHS is unknown, but the present results do seem to echo the findings in other healthcare systems.

The authors thank K. Moorthy, consultant surgeon, and K. Brown, lead theatre nurse, for support and guidance to the main author during this research study; and all operating theatre staff on their contribution to, and participation, in this study.

Disclosure . The authors declare no conflict of interest.

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• health personnel
• operating room
• surgical procedures, operative
• qualitative research
• anesthetists

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The Unique Burial of a Child of Early Scythian Time at the Cemetery of Saryg-Bulun (Tuva)

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Pages:  379-406

In 1988, the Tuvan Archaeological Expedition (led by M. E. Kilunovskaya and V. A. Semenov) discovered a unique burial of the early Iron Age at Saryg-Bulun in Central Tuva. There are two burial mounds of the Aldy-Bel culture dated by 7th century BC. Within the barrows, which adjoined one another, forming a figure-of-eight, there were discovered 7 burials, from which a representative collection of artifacts was recovered. Burial 5 was the most unique, it was found in a coffin made of a larch trunk, with a tightly closed lid. Due to the preservative properties of larch and lack of air access, the coffin contained a well-preserved mummy of a child with an accompanying set of grave goods. The interred individual retained the skin on his face and had a leather headdress painted with red pigment and a coat, sewn from jerboa fur. The coat was belted with a leather belt with bronze ornaments and buckles. Besides that, a leather quiver with arrows with the shafts decorated with painted ornaments, fully preserved battle pick and a bow were buried in the coffin. Unexpectedly, the full-genomic analysis, showed that the individual was female. This fact opens a new aspect in the study of the social history of the Scythian society and perhaps brings us back to the myth of the Amazons, discussed by Herodotus. Of course, this discovery is unique in its preservation for the Scythian culture of Tuva and requires careful study and conservation.

Keywords: Tuva, Early Iron Age, early Scythian period, Aldy-Bel culture, barrow, burial in the coffin, mummy, full genome sequencing, aDNA

Information about authors: Marina Kilunovskaya (Saint Petersburg, Russian Federation). Candidate of Historical Sciences. Institute for the History of Material Culture of the Russian Academy of Sciences. Dvortsovaya Emb., 18, Saint Petersburg, 191186, Russian Federation E-mail: [email protected] Vladimir Semenov (Saint Petersburg, Russian Federation). Candidate of Historical Sciences. Institute for the History of Material Culture of the Russian Academy of Sciences. Dvortsovaya Emb., 18, Saint Petersburg, 191186, Russian Federation E-mail: [email protected] Varvara Busova  (Moscow, Russian Federation).  (Saint Petersburg, Russian Federation). Institute for the History of Material Culture of the Russian Academy of Sciences.  Dvortsovaya Emb., 18, Saint Petersburg, 191186, Russian Federation E-mail:  [email protected] Kharis Mustafin  (Moscow, Russian Federation). Candidate of Technical Sciences. Moscow Institute of Physics and Technology.  Institutsky Lane, 9, Dolgoprudny, 141701, Moscow Oblast, Russian Federation E-mail:  [email protected] Irina Alborova  (Moscow, Russian Federation). Candidate of Biological Sciences. Moscow Institute of Physics and Technology.  Institutsky Lane, 9, Dolgoprudny, 141701, Moscow Oblast, Russian Federation E-mail:  [email protected] Alina Matzvai  (Moscow, Russian Federation). Moscow Institute of Physics and Technology.  Institutsky Lane, 9, Dolgoprudny, 141701, Moscow Oblast, Russian Federation E-mail:  [email protected]

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Operating theatre nurses' with managerial responsibility: Self‐reported clinical competence and need of competence development in perioperative nursing

Ann‐catrin blomberg.

1 Department of Health Sciences, Karlstad University, Karlstad Sweden

Lillemor Lindwall

Birgitta bisholt.

2 Department of Health Sciences, Swedish Red Cross University College, Huddinge Sweden

Associated Data

The data that supports the findings of this study are available in the supplementary material of this article.

The aim of this study was to investigate operating theatre nurses (OTNs) with managerial responsibility, and their self‐rated clinical competence and need for competence development in perioperative nursing.

A cross‐sectional study was applied using a modified version of Professional Nurse Self‐Assessment Scale of Clinical Core Competence I.

Data were collected from 303 OTNs in Sweden, 80 of whom indicated that they had managerial responsibility. Statistics analysis was used to identify the relationships between background variables to compare OTNs with and without managerial responsibility and their need for competence development.

OTNs with an academic degree and managerial responsibility self‐rated their clinical competence higher compared with OTNs without an academic degree. It also turned out that OTNs with RN education and 1‐year advanced nursing in theatre care, and master's 60 credits had a lower need for competence development in cooperation and consultation, professional development and critical thinking.

1. INTRODUCTION

In recent years, conditions in perioperative nursing in Sweden have changed towards increased demand for efficiency and a push for continuity in patient care in an increasingly high‐tech environment (Blomberg et al.,  2014 ). This puts demands on operating theatre nurses (OTNs) with managerial responsibility. Huston ( 2008 ) argued that nurses with management responsibility positions do not have the qualifications required in a complex environment. Leading complex healthcare environments require a more global perspective and thinking. This is to develop nursing, the ability to integrate technology that facilitates mobility and portability of relationships, interactions and operational processes as well as decision‐making based on empirical science. Another aspect worth noting is that in perioperative care in Scandinavia, registered nurses (RNs) with long professional experience are recruited to have managerial responsibility and they are not prepared for what the assignment entails (Solbakken et al.,  2020 ). This was also shown internationally, as was the fact that there was a lack of education in leadership, although OTNs were expected to meet the requirements and responsibilities of being a leader (Beitz,  2019 ; McCallin & Frankson,  2010 ; Pilat & Merriam,  2019 ). During the last year, perioperative care development has increased in Sweden (Blomberg et al.,  2018a , 2018b ), patient flow has increased and OTNs claims that they are not given the opportunity to provide the patient with the care they need. This requires additional education in leadership. Even in nursing education, leadership training is deficient (Francis‐Shama,  2016 ). In Sweden, today there are OTNs with managerial responsibility with varying education and professional experience in perioperative nursing, with or without an academic degree and formal academic leadership education (Blomberg et al.,  2019 ). Despite this, demands are made that they should be able to take responsibility for developing and leading the perioperative practice, while having limited knowledge of leadership, usually given during ongoing assignments. This study was how OTNs perceive their clinical competence in leadership and need for competence development to be able to take full managerial responsibility.

2. BACKGROUND

Within perioperative nursing, OTNs are required to have specific clinical competence to be able to work independently and to cooperate in a surgical team to ensure patient safety. In this study, perioperative nursing is described in relation to Swedish conditions, presented by Blomberg et al. ( 2018 ): Perioperative nursing is a nurse anaesthetists’ and operating theatre nurses’ pre‐, intra‐ and postoperative care for a patient who is undergoing surgery’. Perioperative nursing includes all nursing activities related to the surgical treatments, organization and leadership of the perioperative practice. OTNs with managerial responsibility require skills, knowledge and qualifications in care. The managerial responsibility is described according Wei et al. ( 2019 ) and Jangland et al. ( 2017 ) to be responsible for both the employers work environment and patients’ care to ensure the right competence to achieve a high quality of care. In addition, patients believe that nurses should be competent and that they have interpersonal skills (Smith,  2012 ).

The International Council of Nurses (ICN) emphasizes that the manager has an ethical responsibility to respect human rights, consider human values, to develop and watch over the safety of patients and staff environment (International Council for Nurses,  2013 ). The definition of competence is inconsistent. It has changed over time and varies in different countries (Gunawan et al.,  2020 ). The meaning of the concept of competence can be understood in different ways based on the eye of the beholder. In this study, the meaning of competence is based on Ellström’s ( 1992 ) definition of having the ability to act and perform the specifics of duty in a certain situation and to reflect on and critically analyse and evaluate one's own way of carrying out the work. Clinical competence is not only made up of education and professional experiences, but also the ability to integrate theory and practice. The provision of health professionals with the right competence is the care provider's responsibility and includes both technical and non‐technical skills, as well as opportunities for competence development to be able to take responsibility and ensure patient care (SFS,  2017 :30). Some studies have described OTNs core competencies in Sweden (Falk‐Brynhildsen et al.,  2019 ; Jaensson et al.,  2018 ), it shows that OTNS rated their competence lower in the factor empathy in caring relationship with the patient. OTNS rated itself higher in leadership compared to anaesthesia nurses.

Competence development is described from the technical‐rational perspective where the focus is on achieving the organization's goals, while a humanistic perspective is based on a personal need to achieve the requirements set for the assignment, for example, the development of leadership (Ellström, 1992 ). Competence development in perioperative nursing focuses more on medical technology and needs to be supplemented with education in perioperative nursing care (Blomberg et al.,  2019 ). Smith and Palesy ( 2018 ) also believe that there is a risk that competence in medical technology is given priority over nursing care. Bull and Fitzgerald ( 2006 ) pointed out the importance of combining medical technology with caring to ensure patient safety.

Operating theatre nurses with managerial responsibility must be prepared to relate to organizational changes and create a sense of community in the workplace, where people can experience unity and fellowship of caring while fighting to improve quality of care despite financial pressures (Rudolfsson & Flensner,  2012 ; Rudolfsson et al.,  2007 ). Within perioperative practice in Sweden, there are OTNs with different managerial responsibility as a first‐line manager, nurse assistant manager, section leader and function responsibility. The first‐line manager work closely with patients and employees and have personal responsibility and the assisting nurse manager assists with administrative tasks and practical support for the nurse manager so that they can focus on larger issues and responsibilities. Then, there are also OTNs with responsibility in various sections (e.g. orthopaedics and gynaecology) and function (medical technology and hygiene), within perioperative practice, and all of them have different leadership styles.

Donnelly ( 2017 ) described different leadership styles in perioperative practice and states that a leadership role is assumed by those wishing to initiate change. The transactional leader is the autocratic leader and considered to be controlling with a focus on goal achievement, unlike the transformational leader who has less overall control and encourages employees to be involved in decision‐making. It is essential that nurse managers can develop different leadership styles, appropriate to the demands of the situation (Donnelly,  2017 ). Bondas ( 2003 ) illustrates that nurse managers care about patient needs and describes five relationship‐based rooms that each represent one aspect of leadership.

Caritative leadership is, according to Solbakken et al. ( 2018 ), about nurturing and growing relationships to safeguard the best nursing care. However, it is a challenge to be a nurse manager, and Sørensen et al. ( 2011 ) explain that there is sometimes a conflict between the desire to be clinical and at the same time not being clinical enough, because the managerial responsibility must be prioritized. This leads to being tied up with administrative, managerial and financial duties. Therefore, it is important to investigate how OTNs self‐rated their managerial responsibility, and if they need further competence development. The aim of this study was to investigate OTNs with managerial responsibility, and their self‐rated clinical competence and need for competence development in perioperative nursing.

3. THE STUDY

3.1. design and settings.

This study is part of a larger research project aiming to investigate OTNs’ competence and need for competence development. A cross‐sectional study design was used and conducted in 2016 in Sweden. A questionnaire was used for data collection and all clinically active OTNs working in operating theatres in university, regional/central and district hospitals were invited to participate. Sweden is divided into six medical regions, which organize highly specialized care based on need and availability. In each region, there is a university hospital that besides advanced health care also conducts research and education. Regional/county hospitals offer various general surgical specialties and district hospitals have fewer surgical specialties. In perioperative care, there are active OTNs with different educational backgrounds as OTNs, from 2‐year direct education without postgraduate education in theatre care to RNs with 1‐year advanced nursing in theatre care and master's degree of 60 credits (Table  1 ).

Demographic background of OTNs with managerial responsibility (n = 90)

Abbreviation: RN, Registered Nurse.

3.2. Participants

A convenience sampling was used. In total, 1,057 OTNs were asked to participate, and 303 answered. One of the background variables in the questionnaire was experience of managerial responsibility, which 80 indicated that they had managerial responsibility (Blomberg et al.,  2019 ). They were employed at university, regional/central and district hospitals and had varying lengths of work experience in perioperative care and managerial responsibility. They also had different educational background to become OTNs.

3.3. Instrument and measurement

The modified Professional Nurse Self‐Assessment Scale of clinical competence in perioperative nursing (PROFFSNurse SAS) was used for data collection in the present study. The PROFFSNurse SAS was chosen because it focuses on dynamic and mutual nurse–patient relationships and the theoretical foundation is based on Aristoteles three dimensions of knowledge (episteme, techne and phronesis). It is based on PROFFSNurse SAS I, which in turn, is based on the Nurse Clinical Competence Scale (NCCS). It was tested psychometrically in home care contexts in Norway (Finnbakk et al.,  2015 ). A pilot test was performed on the questionnaire to see if it would be used internationally in the self‐assessment of nurses in postgraduate education and named Professional Nurse SAS II (Taylor et al.,  2020 ; Wangensteen et al.,  2018 ). Prior to use in perioperative nursing, its applicability was ensured by the research team (ACB, LL and BB).

A pilot test was conducted with 10 OTNs from various operating theatres in Sweden. As a result, 10 items were excluded as included clinical assessment of the patient's diagnosis and counselling on prevention and rehabilitation, which were not relevant in perioperative nursing. Approval of the revision was performed by the research group who developed the PROFFSNurse SAS I (Finnbakk et al.,  2015 ). The modified version contained 43 items across six components: Direct clinical practice (15 items), covers important aspects of OTN clinical practice at different educational levels. Professional development (five items) includes being able to take personal responsibility for competence and professional development, as well as participation in quality and improvement work. Ethical decision‐ making (10 items) includes ethical values that take care of patients’ physical, social, mental and spiritual needs, as well as moral commitment in relation to OTNs’ clinical competence. Clinical leadership (four items) includes communicating and taking personal responsibility to make their own decisions as well as being aware of the consequences. Cooperation and consultation (six items) are about cooperation in the surgical team and the need for consultation with other professionals to ensure patient care. Finally, critical thinking (three items) includes how OTNs integrate scientific knowledge into perioperative practice to provide patient safety. The Cronbach's alpha varied between 0.78–0.97 (Table  2 ). Each item was asked referring to self‐assessment of clinical competence and the need for further competence development. The rating scales range from 1–10, where 1 indicates a low level and 10 indicates high levels.

Descriptive statistic for the six components of the modified PROFFSNurse SAS in perioperative nursing ( n  = 80)

3.4. Data collection

Data were collected digitally from the modified questionnaire PROFFSNurse version in perioperative nursing. An inquiry about study participation was made to all heads of departments in all 21 regions/counties in Sweden. One county did not reply and was, therefore, excluded. After the heads of departments had given approval of the study, a contact person was appointed to gain access to the participants’ email addresses. When the participants answered, they also gave their informed consent to participate. A total of four reminders were included and these were sent at 14‐day intervals.

3.5. Data analysis

The analysis of quantitative variables was carried out by calculating participants’ background such as age, educational background, academic degree, place of employment and professional experience in perioperative nursing, and experience of managerial responsibility (Table  1 ). Analytical statistics were performed by analysis of variance (ANOVA) to search for relationships between background factors and the six components of OTNs with or without managerial responsibility. Background factors were tested between main and backgrounds between two factors, both in terms OTNs’ self‐assessment of clinical competence as well as competence development needs. When statistically significant items were detected, a post hoc test analysis was performed using Fisher's LSD to investigate which group differed from the others in each component. The level of statistical significance was set to α = 0.05. Data were analysed using IBM SPSS the Statistic 25.

4.1. Characteristics of the study group

The study included 80 OTNs who had various managerial responsibilities. The average age was about 50 years and 49% of the participants stated that they had <5 years of experience of managerial responsibility. Half of the participants had >20 years of professional experience in perioperative nursing. The participants had different educational backgrounds to OTN, where 30% had a direct education without postgraduate education in theatre care, and more than half no academic degree. The distribution among universities, regional/central and district hospitals was about the same (Table  1 ). The means and standard deviation, as well as how OTNs rated their managerial responsibility regarding clinical competence in the six components is shown in Table  2 . The result includes two parts. The first is a comparison of self‐assessment of clinical competence between OTNs with or without managerial responsibility. Then follows a description of the needs for competence development in their managerial responsibility.

4.1.1. Comparing between OTNs with and without managerial responsibility regarding clinical competence

Operating theatre nurses with managerial responsibility was statistically significant in direct clinical practice, professional development and critical thinking (Table  3 ). OTNs with managerial responsibility (α = 0.001) rated themselves higher in professional development compared to those without managerial responsibility. Analysis of OTNs with managerial responsibility revealed a significant interaction between having an academic degree and having managerial responsibility, regarding direct clinical practice and critical thinking . Participants with master's degree of 60 credits rated themselves much higher in direct clinical practice (α = 0.002) compared to those with a bachelor's degree. Participants with master's 60 credits also self‐rated higher (α = 0.015) regarding critical thinking , but this was only a marginal increase compared with those with a bachelor's degree. OTNs with managerial responsibility and no academic degree rated themselves low in both direct clinical practice and critical thinking . When it came to professional developmen t, a statistical significance emerged between managerial responsibility and education to become an OTN, for participants with managerial responsibility. OTNs with RN education and 1‐year advanced nursing in theatre care rated themselves higher compared to others.

Comparing clinical competence regarding OTN’s with ( n  = 80) and without a managerial responsibility ( n  = 201)

*Significant level at p ‐value > 0.05, measured by ANOVA analysis.

4.1.2. Need for competence development in managerial responsibility

Operating theatre nurses with managerial responsibility and need for competence development emerged as being statistically significant related to an academic degree (Table  4 ). Participants with managerial responsibility and an academic degree had lower need for competence development in Cooperation and Consultation as did OTNs with master's degree of 60 credits in advanced nursing in theatre care (α = 0.001). In general, OTNs with master's degree of 60 credits rated need for competence development slightly lower than those with a bachelor's degree in Professional development and Critical thinking .

Managerial responsibility in relation to need of competence development ( n  = 80)

Operating theatre nurses educational background related to experience of managerial responsibility showed statistical significance related to Clinical leadership, direct clinical practice, professional development and critical thinking . Participants with RN education and 1‐year advanced nursing in theatre care had a lower need for competence development than other participants.

Professional nursing experience in perioperative nursing was shown to have significance in OTNs managerial responsibility, where OTNs with >20 years’ experience had a lower need for competence development compared to other participants. On the other hand, participants with 10–20 years of professional experience had an increased need for competence development in direct clinical practice and critical thinking . What was surprising was that participants <10 years of professional experience had less need for competence development compared to participants with 10–20 years of professional experience (α = 0.001) in Cooperation and consultation .

In experience from managerial responsibility statistical significance emerged in all components (Table  4 ). Participants with <5 years of experience in managerial responsibility had more need for competence development in cooperation and consultation (α = 0.044) compared with participants with >5 years. On the other hand, it emerged that those with <5 years had a lower need for competence development in Ethical decisions making and direct clinical practice compared with those with >5 years.

Another background variable of significance for OTNs managerial responsibility was place of employment when it came to need for competence development. OTNs working in the university hospital (α = 0.001) had a greater need for competence development in Direct clinical practice . There was also a need for competence development in Clinical leadership (α = 0.005) , cooperation and consultation ( α = 0.026) and professional development (α = 0.011) compared with other participants.

4.2. Interactions between background variables and experience of managerial responsibility

The background factors of academic degree, educational background, professional experience in perioperative nursing, place of employment and age in interaction with experience of managerial responsibility were shown to be significant for need for competence development (Table  5 ). All participants with <5 years’ experience of managerial responsibility, with an academic degree, needed competence development compared with those with >5 years. Thus, in ethical decisions‐making, participants without an academic degree had a lower need compared with those with an academic degree. Another factor that was important for managerial responsibility and need for competence development was the education to become an OTN. In cooperation and consultation , all participants with <5 years’ experience of managerial responsibility, regardless of educational background, had need for competence development. OTNs with 2‐year direct education and no postgraduate education in theatre care needed more competence development in clinical leadership and critical thinking compared with others.

Significant interactions between OTNs managerial responsibility and background factors ( n  = 80)

*Significant level at p ‐value > 0.05, measured by ANOVA analysis

Having professional experience in perioperative nursing was shown to be of importance for managerial responsibility, where OTNs with >20 years’ experience had a lower need for competence development. However, participants with <5 years’ experience of managerial responsibility and 10–20 years of professional experience in perioperative nursing (α = 0.047) were shown to need more competence development in clinical leadership. Also, the place of employment was important in need for competence development in cooperation and consultation . OTNs employed at university hospitals with <5 years of experience of managerial responsibility needed more competence development compared with participants at regional/county and district hospitals. It also emerged that OTNs with managerial responsibility needed competence development in cooperation and consultation, but it decreased with increasing age (α = 0.023).

5. DISCUSSION

The study investigated and compared OTNs with and without managerial responsibility regarding clinical competence and their need for competence development. This study shows that OTNs with managerial responsibility with master's degree of 60 credits and RNs with 1 year in advanced nursing in theatre care, self‐rated themselves higher when it came to direct clinical practice, professional development and critical thinking . Aiken et al. ( 2014 , 2017 ) found in their study conducted in Europe that hospitals with a higher proportion of nurses with academic degrees reported a higher degree of quality of care and a better patient safety culture. The results showed that OTNs with an academic degree and education at advanced level have a critical approach and can evaluate and handle various complex situations. This was also proven by another study (Blomberg et al.,  2019 ). Banschbach ( 2016 ) explains that people are not always born to be leaders, and perioperative leaders must understand power issues, must have executive presence and succession planning. Within perioperative practice, it is usual for OTNs with long professional experience to be recruited to assignments with managerial responsibility. These assignments demand that OTNs must be able to strategically plan and organize allocated resources to guarantee patient safety (McCallin & Frankson,  2010 ). Pilat and Merriam ( 2019 ) highlighted that expectations, essential knowledge and skills, graduate education prepared, sought support and mentoring from colleagues and role mastery is not possible. That indicate that there is a lack of education and support in the transition from being clinically active to having managerial responsibility and few onboarding programmes targeted to nurse leader and it is important in their upcoming role as leader. Huston ( 2008 ) was quick to emphasize that nursing education programmes and healthcare organizations must prepare nurses to be effective leaders. Leadership is a central part of nursing and this can be achieved through incorporating leadership learning into clinical skills practice as a continuous theme as soon as RN education starts (Francis‐Shama,  2016 ).

This study showed that OTNs with master's degree of 60 credits and RNs with 1 year in advanced nursing in theatre care also rated themselves high in direct clinical practice . In this study, 70% of the participants had different managerial responsibility and almost worked clinically in perioperative practice, although 30% were first‐line managers. According to Sørensen et al. ( 2011 ), first‐line level leadership is characterized as a balance between proximity and distance to clinical activities. This contrasts to the clinical role based solely on professional experience without theoretical basis, where no development takes place in clinical activities. In the managerial role, a conflict arose between clinical and administrative work. This contrasts the hybrid role where there was an understanding of the use of knowledge based on research. This may indicate that OTNs who have managerial responsibility in this study were, according to Sørensen et al. ( 2011 ), in a hybrid role. Blomberg et al. ( 2019 ) also showed that OTNs without an academic degree wanted competence development in scientific knowledge to be able to participate in quality and improvement work. It also emerged that OTNs’ scientific competence was not utilized to develop perioperative practices. First‐line managers without an academic degree should, therefore, see as an advantage to have OTNs with scientific competence.

Need for competence development in managerial responsibility showed that OTNs with master's 60 credits had a lower need for consultation and cooperation . They generally rated themselves lower in professional development and critical thinking than OTNs with a bachelor's degree. Guo et al. ( 2021 ) show that nurses use a more promoting and constructive voice when they think scientifically and reason logically. Nurses possessing critical thinking can have the ability to make more advanced decisions. The same was shown when participants with <10 years of professional experience in perioperative nursing had a lower need for competence development in consultation and cooperation than OTNs with 10–20 years. Perhaps this can be explained by the fact that they have an academic degree.

On the other hand, it emerged that OTNs with <5 years of experience from managerial responsibility have an increased need for competence development in consultation and cooperation . There are expectations that new nursing leaders have the skills required to carry out assignments. A study of Pilat and Merriam ( 2019 ) showed that the organization needs to invest time and financial resources, as well as offer support to new nursing leaders. New nursing leaders sought the support of other leaders to understand the ethics behind what they do as leaders. A lack of clear expectations, essential knowledge and skills can lead to role insufficiency. Doyle ( 2018 ) also shows that to be able to use situational learning and critical thinking while providing leadership, mentoring and support are required. Gundrosen et al. ( 2016 ) add that there is a need for continuous support both administrative and emotional, along with proper education throughout their time as leaders. OTNs highlighted the need for interprofessional learning with colleagues working with other surgical specialties (Blomberg et al.,  2019 ) and it can also be an option for OTNs with less experience in managerial responsibility. In this study, it emerged that OTNs with 2‐year direct education and no postgraduate education in theatre care rated themselves lower in clinical leadership and critical thinking and need support as they start to become nurse managers.

In terms of educational background, RN participants with 1‐year advanced nursing in theatre care had a lower need for competence development in clinical leadership, direct clinical practice, professional development and critical thinking than others. This can also be attributed to the fact that they have an academic degree. This is also confirmed by Guo et al. ( 2021 ) who believe that nurses with leadership usually accept constructive criticism and take appropriate actions before rigorous assessment of their abilities. Another problem is the loss of experienced OTNs with critical thinking abilities caused by some focusing on managerial responsibility. This directly affects the quality of care and patient safety provided. It also emerged that participants with managerial responsibility employed in university hospitals need competence development in direct clinical practice compared with others employed at regional/central hospitals. This is interesting at university hospitals, where more specialized care is performed and OTNs are faced with greater challenges. This places demands on those with a managerial responsibility.

The background factor of experience from managerial responsibility was also tested regarding interactions between other background factors. It showed that all participants with <5 years’ experience and with an academic degree needed competence development compared with those with >5 years. It emerged that regardless of educational background, there was a need for competence development in consultation and cooperation among OTNs with <5 years’ experience from managerial responsibility. Being able to communicate is, according to Plonien ( 2015 ), the key that opens the door to accomplishment. It is important that the leader adapts his/her way of communicating, both listening and speaking. How the leader conveys and changes communication determines their ability to motivate the team to work more effectively. It also emerged in the study that participants with longer experience in perioperative nursing had less need for competence development in clinical leadership than those with >5 years’ experience of managerial responsibility and 10–20 years. This suggests that, according to Pilat and Merriam ( 2019 ), OTNs with less experience in perioperative nursing need more support and education as they transition into a managerial responsibility. Although the result showed that OTNs with managerial responsibility need competence development, it decreased with increasing age.

5.1. Limitations

Just 30% of the 303 OTNs who participated in the study indicated that they had managerial responsibility (Holbrook et al.,  2007 ). This can be considered low but can still give an idea of how OTNs estimate clinical competence and need of competence development in relation to managerial responsibility. The questionnaire could be answered both via email and mobile phone, which was likely to be beneficial to OTNs. How they indicated what managerial responsibility they had, turned out to be unclear in the questionnaire, and some participants may have missed this. During ongoing data collection, there were also organizational changes, usually involving OTNs with managerial responsibility. This can also be an additional reason for non‐response. The questionnaire chosen for the study had not been psychometrically tested in perioperative nursing but was pilot tested before the study started by OTNs working in different operating theatres in Sweden. The participants’ average age was high, which can be explained by the fact that most OTNs having managerial responsibility have long professional experience from perioperative nursing. It would have been interesting with younger participants and might have influenced the results of the study. A calculation from the National Board of Health and Welfare ( 2018 ) showed that there is a shortage of specialized nurses, including OTNs, and 85% of employers need to employ specialized nurses. In the future, these should be able to have managerial responsibility in perioperative care.

6. CONCLUSION

The study shows that OTNs with managerial responsibility and an academic degree, and RNs with 1year advanced nursing in theatre care have a critical approach and can evaluate and handle various complex situations. It also shows that OTNs with <5 years’ managerial experience have more need for competence development and especially if they were employed at a university hospital. It also emerged that they need support from more experienced OTNs with managerial responsibility, need education in leadership and consultation and cooperation from experienced colleagues at the start. They then need continuous competence development to be able to make the right decisions in different situations that apply to employees and ensure patient care. Further longitudinal studies on OTNs with managerial responsibility regarding their continuous development of competence and need of competence development are of interest.

CONFLICT OF INTEREST

The authors declare that they do not have any conflicts of interest.

ETHICAL CONSIDERATIONS

The study was approved by the local university committee (2015/722). Ethical standards of research were followed in accordance with Declaration of Helsinki ( 2013 ).

ACKNOWLEDGEMENTS

The authors want to thank all the head of departments who were positive about the participation and to all operating theatre nurses who chose to participate in this study. We also want to thank the statistics Jari Appelgren for all the help and support during the statistical processing of data.

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Out of the Centre

Savvino-storozhevsky monastery and museum.

Zvenigorod's most famous sight is the Savvino-Storozhevsky Monastery, which was founded in 1398 by the monk Savva from the Troitse-Sergieva Lavra, at the invitation and with the support of Prince Yury Dmitrievich of Zvenigorod. Savva was later canonised as St Sabbas (Savva) of Storozhev. The monastery late flourished under the reign of Tsar Alexis, who chose the monastery as his family church and often went on pilgrimage there and made lots of donations to it. Most of the monastery’s buildings date from this time. The monastery is heavily fortified with thick walls and six towers, the most impressive of which is the Krasny Tower which also serves as the eastern entrance. The monastery was closed in 1918 and only reopened in 1995. In 1998 Patriarch Alexius II took part in a service to return the relics of St Sabbas to the monastery. Today the monastery has the status of a stauropegic monastery, which is second in status to a lavra. In addition to being a working monastery, it also holds the Zvenigorod Historical, Architectural and Art Museum.

Belfry and Neighbouring Churches

Located near the main entrance is the monastery's belfry which is perhaps the calling card of the monastery due to its uniqueness. It was built in the 1650s and the St Sergius of Radonezh’s Church was opened on the middle tier in the mid-17th century, although it was originally dedicated to the Trinity. The belfry's 35-tonne Great Bladgovestny Bell fell in 1941 and was only restored and returned in 2003. Attached to the belfry is a large refectory and the Transfiguration Church, both of which were built on the orders of Tsar Alexis in the 1650s.  

To the left of the belfry is another, smaller, refectory which is attached to the Trinity Gate-Church, which was also constructed in the 1650s on the orders of Tsar Alexis who made it his own family church. The church is elaborately decorated with colourful trims and underneath the archway is a beautiful 19th century fresco.

Nativity of Virgin Mary Cathedral

The Nativity of Virgin Mary Cathedral is the oldest building in the monastery and among the oldest buildings in the Moscow Region. It was built between 1404 and 1405 during the lifetime of St Sabbas and using the funds of Prince Yury of Zvenigorod. The white-stone cathedral is a standard four-pillar design with a single golden dome. After the death of St Sabbas he was interred in the cathedral and a new altar dedicated to him was added.

Under the reign of Tsar Alexis the cathedral was decorated with frescoes by Stepan Ryazanets, some of which remain today. Tsar Alexis also presented the cathedral with a five-tier iconostasis, the top row of icons have been preserved.

Tsaritsa's Chambers

The Nativity of Virgin Mary Cathedral is located between the Tsaritsa's Chambers of the left and the Palace of Tsar Alexis on the right. The Tsaritsa's Chambers were built in the mid-17th century for the wife of Tsar Alexey - Tsaritsa Maria Ilinichna Miloskavskaya. The design of the building is influenced by the ancient Russian architectural style. Is prettier than the Tsar's chambers opposite, being red in colour with elaborately decorated window frames and entrance.

At present the Tsaritsa's Chambers houses the Zvenigorod Historical, Architectural and Art Museum. Among its displays is an accurate recreation of the interior of a noble lady's chambers including furniture, decorations and a decorated tiled oven, and an exhibition on the history of Zvenigorod and the monastery.

Palace of Tsar Alexis

The Palace of Tsar Alexis was built in the 1650s and is now one of the best surviving examples of non-religious architecture of that era. It was built especially for Tsar Alexis who often visited the monastery on religious pilgrimages. Its most striking feature is its pretty row of nine chimney spouts which resemble towers.

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