Pocket Surgeon App Trains Operating Room Students Faster Than Traditional Teaching Alone

Every operating room team depends on a scrub nurse or surgical technologist who knows the operation almost as well as the surgeon does — the instruments, the sequence of steps, the moment the next clamp or stapler will be needed. Training those people, however, has always run into the same structural wall: real operating rooms are busy, expensive, and not designed for learners to make mistakes in. A new randomized controlled trial published in BMC Nursing suggests that part of that wall can now be dismantled with something as ordinary as a smartphone app.

The study, led by Bahador Pourdel and Erfan Rajabi of Iran University of Medical Sciences together with colleagues at Birjand and Golestan Universities of Medical Sciences, tested the Touch Surgery mobile cognitive simulator on 80 undergraduate operating room technology students. Touch Surgery is not a physical simulator at all. It is a step-by-step cognitive trainer that walks users through the decision tree of an operation — in this case, laparoscopic cholecystectomy, the minimally invasive removal of the gallbladder and one of the most frequently performed abdominal procedures in the world. Users rehearse each phase of the surgery on a screen, selecting instruments and actions in the correct order, and the app scores their performance against the accepted procedural sequence.

The trial was designed as a two-group, parallel randomized controlled trial with repeated measurements, a structure that lets researchers track how each group changes over time rather than comparing them only once at the end. The 80 students were split evenly: 40 received traditional training plus access to the Touch Surgery simulator, while the other 40 received traditional training alone. Randomization was carried out using sequentially numbered opaque sealed envelopes, a standard method for ensuring that neither students nor assessors could predict group assignments in advance. The trial was registered with the UMIN Clinical Trials Registry, although the registration was retrospective — a detail that transparency-minded readers will note.

What makes the study technically interesting is the breadth of its outcome measures. Knowledge of the surgical procedure was tested with a previously validated instrument, whose content was checked using the content validity ratio and content validity index, two quantitative measures of how well test items represent the domain they are meant to cover. Simulated scrub-role performance was scored with a Skill Lab observational checklist, in which trained observers rate each student’s hands-on behavior in a mock operating room. Perceived competence was measured with the Perceived Perioperative Competence Scale-Revised, and safety attitudes with the Safety Attitudes Questionnaire, an instrument originally developed to gauge the safety climate of real clinical teams. Data were collected at three points: baseline, immediately after the intervention, and again four weeks later.

The statistical engine behind the analysis was repeated measures analysis of variance, which partitions the observed variation into components attributable to time, group, and the interaction between the two. That interaction term is the crucial one. A significant time-by-group effect means the two groups did not merely improve at different absolute levels — their trajectories of change diverged over the course of the study, which is the strongest evidence a repeated measures design can offer that the intervention itself drove the difference.

And diverge they did. For knowledge of the surgical procedure, the interaction effect was highly significant, with a partial eta-squared of 0.147 — a medium-to-large effect indicating that roughly 15 percent of the variance in knowledge change over time was explained by group membership. For simulated clinical performance, the effect was even larger: partial eta-squared of 0.195 and a Cohen’s d of 1.08, which in conventional terms is a very large standardized difference. In plain language, students who rehearsed the operation on the app did not just know it better on paper; they performed measurably better in the simulated scrub role, anticipating instrument needs and procedural steps with greater accuracy than their traditionally trained peers.

Perhaps the most striking result concerned perceived competence. The experimental group’s confidence in their own perioperative abilities rose considerably faster than the control group’s, with a partial eta-squared of 0.269 — the largest effect size in the entire study. Confidence is a delicate variable in surgical education. Too little, and learners hesitate at the scrub table; too much, without the skills to back it, and safety suffers. Here, the app appeared to build confidence in parallel with demonstrated performance, which is exactly the pairing educators hope for. The authors conclude that Touch Surgery represents an effective complement to surgical training, contributing to rapid improvement in cognitive skills and simulated scrub-role performance while increasing perceived competence.

One measure, however, refused to move. Scores on the Safety Attitudes Questionnaire showed no statistically significant difference between the two groups over time, with a p-value of 0.373. The authors offer a candid interpretation: shifting safety attitudes may require more than individual cognitive rehearsal. Safety culture, they suggest, is a property of teams and clinical environments, not of solo learners practicing on a screen. Inducing meaningful change in how students think about operating room safety may demand that cognitive simulators be integrated into team-based clinical settings, where communication, situational awareness, and shared decision-making can be rehearsed alongside procedural knowledge.

The implications reach beyond one app and one procedure. Surgical training worldwide is confronting structural limits — limited operating room time, rising costs, and growing cohorts of learners — that have fueled a global movement toward mobile cognitive simulators. This trial provides randomized evidence that such tools can accelerate the cognitive and simulated technical components of scrub-role training for the people who keep the operating room running. At the same time, the null result on safety attitudes is a useful corrective to hype: a phone app can teach the sequence of an operation, but it cannot yet teach a team how to be safe. The study received no external funding, was approved by the Birjand University of Medical Sciences Research Ethics Committee, and was conducted in accordance with the Declaration of Helsinki, with informed consent obtained from all participants. The authors declare no competing interests. As operating room technology programs weigh how to stretch scarce clinical placements, the message of this trial is measured but clear — cognitive simulators belong in the curriculum, as a complement to the operating room, not a replacement for it.

Subject of Research: Effect of the Touch Surgery mobile cognitive simulator on surgical knowledge, simulated scrub-role performance, and perceived perioperative competence in operating room technology students

Article Title: Effect of a mobile-based cognitive simulator (Touch Surgery) on knowledge, simulated scrub-role performance, and perceived perioperative competence among operating room technology students: a randomized controlled trial

Article References: Pourdel, B., Rajabi, E., Memarbashi, E., & Hosseini, S. A. (2026). Effect of a mobile-based cognitive simulator (Touch Surgery) on knowledge, simulated scrub-role performance, and perceived perioperative competence among operating room technology students: a randomized controlled trial. BMC Nursing. https://doi.org/10.1186/s12912-026-05317-0

Image Credits: AI Generated

DOI: 10.1186/s12912-026-05317-0

Keywords: Touch Surgery, surgical simulation, mobile cognitive simulator, laparoscopic cholecystectomy, operating room technology, scrub role, perceived perioperative competence, randomized controlled trial, surgical education, BMC Nursing, safety attitudes, perioperative training