Poor Learning In Operation Theatres Causing Brain Drain

Introduction: In interior Sindh, most of the hospitals including teaching hospitals of Hyderabad, Larkana, Sukkur and Nawabshah lack specialists so the attitude of available specialists as supervisors is important for learning in operation theatre like need good mentorship, observation and hands-on skills. Limited research has been conducted in Pakistan while none of the study has been done considering specifically the hospitals of interior Sindh. Objective: To identify the perception of residents towards learning environment in surgical theatre of a medical school teaching hospital of interior Sindh. Method: A cross-sectional study was conducted at Peoples Medical College, Nawabshah, from May 2018 to October 2018. STEEM questionnaire of 40 statements was used and was validated after pilot study. The participants' responses were calculated using a five-point Likert scale. Randomized sampling technique was used. The reliability was assessed using Cronbach's alpha for the whole questionnaire. Mann-Whitney and the one-way analysis of variance (ANOVA) tests were used as nonparametric methods for comparative statistics for assessing gender differences. We also conducted the factor analysis by using a varimax rotation. Kaiser-Mayer-Olkin (KMO) and Bartlett's tests were applied. Results: Of the 88 participants, 71.6% (n=63) were females and 28.4% (n=25) were males. Majority of participants 43% belong to gynaecology department. The reliability of the scale was 0.822, calculated using Cronbach alpha. The mean overall STEEM score was 108.81 whereas, mean score of males was 115.44 and females was 106.17 which shows there the difference between scores based on gender. Male perceived the educational environment more positive than females in each subscale. Conclusion: Under current circumstances and condition of interior Sindh postgraduate trainees are deprived from good mentorship, observation and hands on skills due to lack and non-serious attitude of consultants/supervisors. The current study concluded that overall learning environment of operating theatre was perceived to be inadequate for learning. Sadiq S, Qureshi M, Lakhani M, Shah M, Ayub M MedEdPublish https://doi.org/10.15694/mep.2019.000131.1 Page | 2


Introduction
The educational environment is an important measure, which has a large effect on the satisfaction, achievement, and success of medical education. Positive learning climates have been associated with improved learner's performance (Genn, 2001a;Genn, 2001b;Binsaleh et al., 2015). The practice and discipline of surgery is one that is complex and multifaceted, incorporating many key elements such as issue manipulation, sound clinical judgement, ever-present conscientiousness and leadership (Hu, Wattchow and de Fontgalland, 2018). Learning environment is an important factor in determining the outcomes of the curriculum, learning, student's achievement, satisfaction (Al-Qahtani and Al -Sheikh, 2012). A good learning environment should ideally include the physical, psychological, social and educational domains of a training programme which are thought to play a vital role in the professional and moral developments of the trainees (Soomro, Rehman and Hussain, 2017). Surgical trainees and surgeons thought that all competencies of surgery can be learnt and taught in the operating theatre so need constructive atmosphere for better outcomes (Kieu et al., 2015).
Looking over the health sector in Sindh, faces enormous challenges. In interior Sindh, most of the hospitals including teaching hospitals of Hyderabad, Larkana, Sukkur and Nawabshah lack specialists such as urologists, neuro-surgeons and paediatrics surgeon, radiologists, pathologists, orthopaedic surgeons, eye and ENT specialists, senior physicians and general surgeons. Beside these circumstances, the attitude of available specialists as supervisors is important for learning in operation theatre like need good mentorship, observation and hands-on skills (Paice, Heard and Moss, 2002;Imran, Haider and Bhatti, 2011).
Many studies have been carried out throughout the World but limited research has been conducted in Pakistan (Sheikh et al., 2017;Soomro, Rehman and Hussain, 2017;Kamran et al., 2018) while none of the study has been done considering specifically the hospitals of interior Sindh. Therefore, the primary objective of this study was to identify the perception of residents towards the learning environment in the surgical theatre of a medical school teaching hospital of interior Sindh.

Methods
A cross-sectional study was conducted at Peoples Medical College, Nawabshah, from May 2018 to October 2018. We included all the surgical and allied trainees working in 8 different departments of PMC. We calculated our sample size by using Openepi calculator. We excluded all the registrars and senior registrars from the study to avoid observation bias due to their completion of trainings. A formal consent form was then formulated for the participants including their gender. The study was also approved by Ethical Review Committee of Ziauddin University.
A 40 item questionnaire called surgical theatre educational environment measure (STEEM) was used (Cassar, 2004). We assessed the practicality of using the STEEM questionnaire by conducting a pilot study, the results were promising on a small sample size of 20 with a global reliability within acceptable range. This validated the STEEM tool for our assessing learning environment. The participants' responses were calculated using a five-point Likert scale. These ranged from strongly agree (5), agree (4), uncertain (3), disagree (2) to strongly disagree (1). The minimum score was 40 and possible maximum score was 200. A score of at least 120 out of 200 was considered favourable. The value above 120 indicates a more satisfactory educational environment.
The STEEM questionnaire was divided into four subscales: trainees' perceptions of their trainer and training (questions 1-13); trainees' perceptions of learning opportunities (questions 14-24); 1. Trainees' perceptions of atmosphere in the operating theatre (questions 25-32); and trainees' perceptions of supervision, workload and support (questions 33-40). The questionnaires were distributed and collected from the participants after completion within a day. Randomized sampling technique was used.
The reliability was assessed using Cronbach's alpha for the whole questionnaire. Mann-Whitney and the one-way analysis of variance (ANOVA) tests were used as nonparametric methods for comparative statistics for assessing gender differences. There were 19 negative statements for which reverse coding were done when they were analysed. We also conducted the factor analysis by using a varimax rotation. Kaiser-Mayer-Olkin (KMO) and Bartlett's tests were applied. The data was analysed using SPSS 22. Confidence of interval was set to be 95% with 5% margin of error.

Results/Analysis
Of the 88 participants who completed the questionnaire, 71.6% (n=63) were females and 28.4% (n=25) were males. Doctors from different departments were included in the study, majority of participants 43% belong to gynaecology department followed by general Surgery (24%), eye (13%), Neurology (6%), Orthopaedics (6%), Urology (5%), Paediatrics (2%) followed by ENT (1%). Questionnaire consist of 40 statements which were marked by Likert Scale maximum score was 200 and minimum score was 40, score above 120 was considered to be a favourable for learning. The mean overall STEEM score was 108.81 whereas, mean score of males was 115.44 and females was 106.17 which shows there the difference between scores based on gender. Mann-Whitney and one-way analysis of variance (ANOVA) test were used as non-parametric methods for comparative statics for assessing gender differences as shown in Table 1 and 4.  The overall reliability of the scale was 0.822, calculated using Cronbach alpha. We also calculated the mean, standard deviation, confidence interval and reliability (Cronbach alpha) of each sub-scale and the whole scale as shown in Table 2. 0.822 There were 19 negative statements for which reverse coding were done when data was analysed. We also conducted factor analysis using a varimax rotation. Kaiser-Mayer-Olkin (KMO) and Bartlett's test were applied, results of factor analysis at Eigen value set at 1 revealed 10 factors which showed 84.78% of the variance. The overall reliability and mean scores for Aberdeen surgical trainees, Birmingham Medical Students, Liaquat National Hospital trainees was compared to scores of one of the hospital of rural area of Sindh like People Medical College Nawabshah trainee as shown in Table 3. The most highly rated statement was 'The anaesthetists put pressure on my trainer to operate him/herself to reduce aesthetic time' (3.84) and the lowest rated statement was 'My trainer's surgical skills are very good'. Looking over the gender variation, the most highly rated statement among men was 'The nursing staff dislike it when I operate as the operation takes longer' (3.72) and lowest rated was 'My trainer's surgical skills are very good' (1.52), whereas the most highly rated statement among women was 'The anaesthetists put pressure on my trainer to operate him/herself to reduce aesthetic time' (3.90) and lowest rated was same as that among men (1.37). Male perceived the educational environment more positive than females in each subscale. There were seventeen statements with a statistically significant difference between genders (p<0.05), shown in table 4.

Discussion
Surgeons and medical students are involved in a continuous dynamic of observing each other's behaviour. Surgeons have to consider the needs of different learners in theatres and decide how to distribute valuable teaching time and opportunities for involvement in the team (Patricia Lyon, 2004). The operating theatre is a challenging place to learn and develop skills, good committed surgical educators in theatres are always acknowledged and rewarded (Patricia MA Lyon, 2003).
We compared reliability scores of overall questions which was found to be 0.82 which was more than Aberdeen and Birmingham study. Our study appeared to be successful in showing that the STEEM questionnaire is a reliable, dependable and practical tool for evaluating the operating theatre learning environment of postgraduate surgical trainees in PMC Nawabshah. The mean overall STEEM score was 108.81. This score indicates that current learning environment is not suitable for learning. The mean score of males was 115.44 and that of females was 106.17. Overall male trainees rated the environment as more positive than their female counterparts. The scores were compared with the students of Birmingham study and Aberdeen study which showed mean score of 149 and 139 respectively which indicates the suitable learning environment and there was no discrimination based on gender but on the other hand it was also compared with mean score of Liaquat National Hospital Karachi trainees that was 136 which is suggestive of positive learning environment but there was discrimination based on gender and male rated the learning environment better than their female counterparts (Cassar, 2004;Nagraj, Wall and Jones, 2006;Soomro, Rehman and Hussain, 2017). Difference between the results of our studies compared to others can be due to the poor facilities, management, lack of professionalism and gender discrimination in interior Sindh like Nawabshah.
Data was also analysed on the basis of its sub-scales for better understanding of reason for non-favourable learning environment. The trainees' perception of their trainer and teacher (Q1-13) has an average rating of below the midpoint. However, Q11 is an exception where the average rating is above the midpoint (3.73). This suggests that trainees are satisfied with the teaching skills of their trainers and but find it difficult to live up to the unrealistic expectation of the trainer regarding their surgical skills. A study published in Journal of surgical education emphasized on the fact that faculty should be aware that there may be discrepancies between their perception of residents' learning needs and residents' expressed learning needs, needs assessments may help to identify such discrepancies and clarify the best options for addressing the learning needs of residents (Pugh et al., 2007), our study also supports this and adjustments in resident work load, behaviour of seniors and staff, genuine interest in teaching and learning and development of surgical skills laboratories can play a critical role in residents' learning needs.
A supportive atmosphere has been found to be a key element in achieving a sense of psychological safety and thus Sadiq S, Qureshi M, Lakhani M, Shah M, Ayub M MedEdPublish https://doi.org/10.15694/mep.2019.000131.1 Page | 9 an important element in manifesting the existence of participatory practices in the workplace, in our setup sub-scale labelled 'Trainees' perception of the atmosphere in the operating theatre' (Q25-32) gives the impression that OT environment is not suitable for learning. The nursing staff and anaesthetists prefer that the trainer complete the surgery, as trainees take longer. This results in trainees not getting sufficient practice to improve their skills. Trainees also feel that there is a gender bias (Collin, Paloniemi and Mecklin, 2010). Trainees' perception of supervision, workload and support (Q33-40) is rather bleak. They feel overwhelmed due to the workload. Low support provided to them along with high expectations of their performance, results in less people opting for surgery (Wålinder et al., 2018).
In our study, we identified that with the Eigen value set at 1, there were only 10 components factors, which covered 85% of the variance. This will help in modifying the STEEM questionnaires in a more comprehensive and better manner. This study was limited to the surgical trainees of Peoples Medical College, Nawabshah, Pakistan. Hence no generalization can be made on basis of our study, we recommend to get a more appropriate picture of the condition in interior region of Pakistan, and studies of this type should be carried out at a larger scale including all major cities.

Conclusion
Under current circumstances and condition of interior Sindh postgraduate trainees are deprived from good mentorship, observation and hands on skills due to lack and non-serious attitude of consultants/supervisors. The current study concluded that overall learning environment of operating theatre was perceived to be inadequate for learning.

Take Home Messages
Under current circumstances and condition of interior Sindh postgraduate trainees are deprived from good mentorship, observation and hands on skills due to lack and non-serious attitude of consultants/supervisors. The current study concluded that overall learning environment of operating theatre was perceived to be inadequate for learning.

Notes On Contributors
Dr Sara Sadiq: Conceptualized and designed this study; developed and designed the tools for the acquisition of the quantitative data and analysis and interpretation; drafted the manuscript and performed critical revisions of the manuscript; provided final approval of the version to be published. She is currently working as Assisntant Proffesor in Department of Physiology.
Muhammad Fazal Hussain Qureshi: Conceptualized and designed this study; developed and designed the tools for the acquisition of the quantitative data and analysis and interpretation; drafted the manuscript and performed critical revisions of the manuscript; provided final approval of the version to be published. He is a third year MBBS student in Ziauddin University.
Mahira Lakhani: Conceptualized and designed this study; developed and designed the tools for the acquisition of the quantitative data and analysis and interpretation; drafted the manuscript and performed critical revisions of the manuscript; provided final approval of the version to be published. She is a third year MBBS student in Ziauddin University.
Muzna Shah: Conceptualized and designed this study; developed and designed the tools for the acquisition of the Page | 10 quantitative data and analysis and interpretation; drafted the manuscript and performed critical revisions of the manuscript; provided final approval of the version to be published. She is a third year MBBS student in Ziauddin University.
Muhammad Hassan Ayub: Conceptualized and designed this study; developed and designed the tools for the acquisition of the quantitative data and analysis and interpretation; drafted the manuscript and performed critical revisions of the manuscript; provided final approval of the version to be published. He is a third year MBBS student in Ziauddin University.