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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 29  |  Issue : 3  |  Page : 256-261

Surgical resident doctors' perception of their training using Surgical Theatre Educational Environment Measure (STEEM) tool in postgraduate surgical residency training institutions in Nigeria


1 Department of Surgery, Faculty of Clinical Sciences, College of Medicine, University of Lagos, Lagos, Nigeria
2 Department of Senate and Governing Board Affairs (SGBA), National Postgraduate Medical College, Lagos, Nigeria

Date of Submission05-Apr-2022
Date of Decision13-May-2022
Date of Acceptance27-Jun-2022
Date of Web Publication22-Jul-2022

Correspondence Address:
Olumide Abiodun Elebute
Department of Surgery, Faculty of Clinical Sciences, College of Medicine, University of Lagos, P.M.B 12003, Idi-Araba, Lagos
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/npmj.npmj_91_22

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  Abstract 


Introduction: Postgraduate Medical Education is 'the constellation of learning activities carried out to enable doctors to develop relevant competencies and deeper knowledge in specific subject areas after completion of basic medical education'. The purpose of this study was to examine the perception of surgical resident doctors of their training in accredited institutions in Nigeria, using the Surgical Theatre Educational Environment Measure (STEEM) inventory. Methods: The study was a cross-sectional observational study that employed the STEEM instrument which was administered online via email to surgical resident doctors in all the surgical residency training institutions in Nigeria accredited by the National Postgraduate Medical College of Nigeria. The STEEM is a validated 40 item, self-administered questionnaire. Statistical analysis was performed using SPSS version 23. Cronbach's alpha was calculated for the whole STEEM and the sub-scales for both reliability and internal consistency. Results: One hundred and sixty-six respondents filled the questionnaire out of 464 people contacted, giving a respondent rate of 35.7%. There were 156 (94.0%) males and 10 (6.0%) female respondents. One hundred respondents (60.2%) had global STEEM scores less than the benchmark of 120, three (1.8%) with scores of 120 and 63 (38.0%) had scores >120. Conclusion: The majority of the respondents in our study indicated dissatisfaction with their operational educational environment experience.

Keywords: Learning environment, postgraduate education, resident doctor, STEEM, surgical theatre


How to cite this article:
Elebute OA, Sule SS, Mofikoya BO, Jeje EA, Atoyebi OA. Surgical resident doctors' perception of their training using Surgical Theatre Educational Environment Measure (STEEM) tool in postgraduate surgical residency training institutions in Nigeria. Niger Postgrad Med J 2022;29:256-61

How to cite this URL:
Elebute OA, Sule SS, Mofikoya BO, Jeje EA, Atoyebi OA. Surgical resident doctors' perception of their training using Surgical Theatre Educational Environment Measure (STEEM) tool in postgraduate surgical residency training institutions in Nigeria. Niger Postgrad Med J [serial online] 2022 [cited 2022 Aug 13];29:256-61. Available from: https://www.npmj.org/text.asp?2022/29/3/256/351728




  Introduction Top


Postgraduate Medical Education (PME) has been variously defined as 'the constellation of learning activities carried out to enable doctors to develop relevant competencies and deeper knowledge in specific subject areas after completion of basic medical education'[1] and incorporates educational experiences that support the resident doctor's acquisition of the knowledge and skills characteristic of the area of specialisation.[2] PME in Nigeria is patterned, to a large degree, after the British model, with some admixture of both American and Canadian curricula.[1] The aspiring surgical trainee is admitted into the Junior residency position, in one of several tertiary health institutions in the country, after passing the entrance examination into PME (otherwise referred to as primary examination) administered by the two Postgraduate Medical Examinations bodies in Nigeria, the National Postgraduate Medical College of Nigeria and the West African College of Surgeons.[3] In general, this period of training lasts between 2 and 3 years, to qualify for the Part 1 examination which grants access to the next phase in the training, the Senior or Specialist Registrar post. This takes a minimum of two and a half years for completion of the relevant clinical rotations, after which the trainee is eligible for the exit examination or the Part 2 fellowship examination to be certified as a specialist or consultant surgeon.[1],[3],[4]

An integral component of any surgical training is exposure to operation in the surgical theatre, which is to build up professional competency in the delicate art of surgery through both knowledge and technical skills acquisition. Studies have highlighted the role of the learning environment in achieving this desired goal.[5],[6] The ideal environment should support a blend of supervised exposure to graded operative experience and didactic sessions with feedback and not be a unidirectional flow of information or instruction.[7] Previous multicentre studies in Nigeria by Taiwo et al.[8] and Ogunnubi et al.[4] offered conflicting reports about the perception of surgical trainees of their theatre environment learning experiences. It is obligatory that postgraduate colleges that have been vested a lot of resources, with the solemn responsibility of overseeing training, be fully abreast with the current perceptions of those who are recipients of this training so that they are better positioned to appropriately advise designated training institutions of identifiable deficits. The purpose of this study is to examine the demographic characteristics and perception of surgical resident doctors in their training in residency training institutions in Nigeria using the Surgical Theatre Educational Environmental Measure (STEEM).


  Methods Top


Study population

The study population consisted of doctors undergoing residency training in the various training institutions in Nigeria, who were registered as trainees with the National Postgraduate Medical College of Nigeria. The study period spanned from July 2020 to March 2021. The email addresses of potential participants used to distribute the STEEM questionnaire were retrieved from the records of residents who had registered for postgraduate training with the National Postgraduate Medical College, with due permission from the College Authorities.

Sample size

The authors could not lay hold on the data of the total number of residents undergoing training in surgery or surgery-related specialities in the country, but we estimated a total of 1000. Based on this assumption, with a marginal error of 5% and a confidence interval of 95%, we arrived at a sample size of 285.

Study design

This was a cross-sectional observational study that employed the Surgical Theatre Educational Environment Measure (STEEM). It involved the administration of the STEEM questionnaire online, to be completed and submitted by surgical resident doctors in all surgical training institutions accredited by the National Postgraduate Medical College of Nigeria. The STEEM questionnaire on the perception of surgical resident doctors was sent to a total of 464 eligible individuals, out of which 166 from 77 training institutions responded.

Instrument

The STEEM is a validated 40 item, self-administered questionnaire devised by Cassar in 2004[3] to assess the surgical theatre environmental experiences of trainees. This instrument has been used to evaluate the surgical training experiences of residents in various parts of the world. It consists essentially of four sub-scales, notably the trainee's perception of the trainer and training, the learning opportunities, the atmosphere in the operating theatre and lastly, supervision, workload and support. The response to each of the 40 items was graded using a 5-point Likert scale, 1 (strongly disagree), 2 (Disagree), 3 (not sure), 4 (agree) and 5 (strongly agree). A reversal of the coding was performed for negative questions, namely-8, 11, 14, 16, 19, 22, 23, 26, 27, 28, 30,31, 33, 34, 35, 36, 37, 38 and 40. Higher scores were indicative of higher perception. The questionnaire was prepared as a Google Forms and delivered to the E-mail boxes of the respondents as a bulk email, with a brief explanation of the purpose of the study. Other personal data such as gender, place of training, postgraduate year, area of specialisation and cadre in residency were included in the form. The respondents were guaranteed anonymity of their responses. The questionnaire took an average of 10 min to complete.

Analysis

Statistical analysis was performed using SPSS version 23 (IBM Corp. Released 2015. IBM SPSS Statistics for Windows, Version 23.0. Armonk, NY, USA: IBM Corp). The mean for each of the 40-item responses and the mean of each response in each subsection were calculated. One-way analysis of variance was used to assess the significance of differences within the geographical locations of the training site, postgraduate year of the respondent, gender, area of specialisation and also within STEEM scores. Categorical variables were compared using the Chi-square test. Spearman's correlation was used to determine the relationships between socio-demographic, gender, postgraduate year of the respondent and the subscales scores.

Cronbach's alpha was calculated for the sub-scales for both reliability and internal consistency and the whole STEEM. A value of P < 0.05 was considered statistically significant.


  Results Top


Demographics

One hundred and sixty-six respondents filled the questionnaire out of a total of 464 people contacted, giving a respondent rate of 35.7%. There were 156 (94.0%) males and 10 (6.0%) females.

Status within the residency programme or postgraduate year

One hundred and four respondents (62.6%) had their primary training institution located in the southern part of the country. Seventy-five respondents (45.2%) were <3 years into their junior residency training and a further 38 (22.8%) were at least 3 years into the senior or specialist programme [Table 1].
Table 1: Characteristics of the respondents


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The Cronbach's alpha internal consistency reliability for the STEEM questionnaire, the sub-scales and the overall scores, for our study, are shown in [Table 2].
Table 2: Cronbach's alpha analysis for internal consistency reliability

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One hundred respondents (60.2%) had global STEEM scores <120, three (1.8%) with scores of 120 and 63 (38.0%) had scores >120 [Table 3]. There were 96 (57.8%) males and 4 (2.4%) female respondents who had global sores <120. The majority of these (45 respondents [27.1%]) indicated that they were 3 years into their residency training [Table 4]. There was no statistically significant relationship between the global STEEM scores and the sex of the respondents, the postgraduate year of the trainee, the region of the country where primary training took place as well as the area of speciality [Table 4].
Table 3: Global or overall scores from the surgical theatre educational environment measure questionnaire

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Table 4: Comparing the global surgical theatre educational environment measure score with sex, post-graduate year, region in the country and sub-speciality/speciality

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Questions ranking

The lowest ranking question was question 6 (mean 1.54 ± 0.74), whereas the highest was question 30 (mean 4.71 ± 0.74) and question 31 (mean 4.68 ± 0.79) [Table 5].
Table 5: The descriptive statistics for each question in the surgical theatre educational environment measure questionnaire

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Subscale 1-Perception of trainer and training Q1-13

The highest means were recorded for questions 8, 'My trainer immediately takes the instruments away when I do not perform well' (3.42 ± 1.12) and 10, 'Before the operation my trainer discusses what part of the procedure I will perform' (3.17 ± 1.26) in the first subscale-Perception of trainer and training [Table 5].

Subscale 2-Perception of learning opportunities Q14-24

Similarly, the highest recorded means in sub-scale 2, Perception of learning opportunities, were those accorded to question 14, which compared the complexity of operative exposure to the trainee's experience (3.90 ± 1.02) and question 16, which referred to the number of cases the trainee is allowed to participate in (3.60 ± 1.15) [Table 5].

Subscale 3-Perception of atmosphere in the theatre Q25-32

The highest means were question 30, which pointed to gender discrimination and question 31, tribal discrimination. Q32 scored the lowest mean in the subset of questions [Table 5].

Subscale 4-Perception of supervision, workload and support

All questions, except Q39, had a mean above 3 [Table 5].


  Discussion Top


There was a preponderance of male resident doctors in postgraduate surgical training, in keeping with the findings of other studies.[7],[9],[10] Approximately two-thirds of the training institutions were situated in the southern part of the country, which probably reflects the southern region's hegemony over education in Nigeria as educational and health facilities are more concentrated there than in the other parts of the country.[11],[12]

The overall Cronbach's alpha analysis for internal consistency of our study, Q1-40 (40 items) was 0.910, we thus agree with the assertion by other researchers that the STEEM inventory is a reliable tool in evaluating residents' doctors' surgical theatre learning experience.[13],[14],[15] Our study demonstrated a higher value than the findings of Binsaleh et al.[15] who obtained a score of 0.862, from their work on surgical residents in Saudi Arabia, but similar to that of Mahoney et al.,[5] with a score of 0.91, from a study evaluating Australiasian surgical trainees' experiences. Also noted was that the four sub-scales, from our analysis, had differing Cronbach alpha values, indicating the 'discriminatory distinctiveness' as alluded to by Taber,[16] which shows that each subscale measures an entirely different component from the others [Table 2].

We found no other study conducted in Nigeria or Africa as a whole, for comparison, that specifically utilised the STEEM questionnaire. Thirty-eight per cent of doctors in our study perceived that their theatre learning experience was satisfactory. This is much lower than most studies we reviewed. Soomro et al.[14] in Pakistan reported a finding of 69.5%, from their research on resident doctors in Liaquat National Hospital, Karachi, Pakistan and Austen et al.[17] in the United Kingdom obtained a value of 67.7% in their study on Podiatric surgical trainees. The low rating in our study may be because, in sharp contrast to the countries where these two studies were generated, Nigeria is grappling with an abysmally low budgetary allocation to the public health institutions, in which many of the respondents are based. The country's budgetary allocation for health has consistently fallen short of the expected 15% benchmark of the national total budget. This has resulted in dwindling funding for existing health facilities in the country, leading to failing health service delivery and suboptimal training environments. Furthermore, there has been a mass exodus of health workers to other countries in search of greener pastures, leaving training centres bereft of competent trainers.

Ibrahim et al.[7] in Nigeria rated their respondents' operating theatre satisfaction as 67.5%, but in contradiction to our study, where the respondents were recruited from training institutions all over the Federation, their study was a single-institutional work, involving a smaller population size. Furthermore, although the authors utilised the Operating Theatre Education Environment Measure, which is a 33-item instrument, with a Cronbach's alpha score of 0.811, their work was published nine (9) years ago and the findings may not be a true reflection of current perception.

Our study reveals some level of dissatisfaction existing among trainees undergoing medical training in Nigeria, which has been previously corroborated by several authors.[4],[19],[20],[21] Anyaehie et al.[21] reported the overall assessment of surgical training by Resident doctors in the South-Eastern part of the country as 53.3%. They identified inadequate practical exposure and paucity of surgical equipment as areas responsible for the poor rating in their study.[21]

The authors equally concluded that inadequate teaching and supervision by trainers was one other factor responsible for the poor rating they witnessed. We equally noted that 11 of the 13 statements in Sub-scale 1, that assess the trainee-trainer relationship, had mean values <3, which appears to lend credence to their findings. Jeje et al.[20] in their work on Postgraduate residents' mentorship experiences in Nigeria and Yusufu et al.[22] on a study focusing on residents' perception of their training in one of the Northern tertiary institutions in Nigeria expressed the opinion that the majority of residents considered contributions by consultants to their training as being subpar, further buttressing the wide gap existing between trainees and trainers in many training institutions.

We observed that in contrast to Mahoney et al.'s[5] work on Australasian surgical trainees, the proportion of residents satisfied with their training environment in our study had no bearing on their postgraduate year, but was relatively consistent.

The lowest sub-scale means in our study was for 'Perception of the atmosphere within the theatre (Q25-32). The highest means in the entire study were for questions 30, 'I feel discriminated against in theatre because of my sex' and question 31, 'I feel discriminated against in theatre because of my tribe,' whereas in Q32, 'I feel part of a team in theatre,' scored the lowest mean in the subset of questions. The latter was statistically significant for the sex and postgraduate year of the respondent, although with a weak correlation [Table 6]. Seven of the female residents in our study 'strongly disagreed,' with the Q32 statement, while Q30, witnessed a similar outcome (7 females out of 10).
Table 6: Statements in the questionnaires that were statistically significant with corresponding variables

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This tallies with the findings of several other researchers who have reported, that many female residents allege some form of discrimination based on their gender. Although our study did not delve into the reason for this perceived notion, we opine that this may not be unconnected with the assumption of Bellini et al.[18] that surgery is perceived as a 'male-dominated profession.' From their report, over half of the respondents perceived discrimination in their practice and a fifth believed that there existed a 'glass-ceiling' in their respective careers.

Limitations

Our study had a very limited number of respondents from privately-owned surgical training centres. This limited the coverage of the study. The responses from these institutions could have altered the general perception obtained from the study.

The low respondents rate witnessed in our study could be attributable to the fact that the questionnaire sent via email could have been diverted into the spam box of the recipients, added to this is probably the lack of incentive attached to the filling of the questionnaire. A more probable way around this would be to target training workshops or update courses and have the questionnaire disseminated at these points to participants. It is believed that responses would be much better with live interactions than with the mere sending of questionnaires to participants' email boxes.


  Conclusion Top


This study concluded that the majority of the respondents indicated dissatisfaction with their surgical operation environment training experience. It is thus recommended that training institutions should aim at providing a more enabling training environment and that trainers and trainee relationships would be more consolidated, with better supervision and interaction.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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