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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 15  |  Issue : 3  |  Page : 235-239

A survey study on self-reported practice and work environment among anesthetist trainees in Nigeria


Department of Anaesthesia, University of Ibadan; Department of Anaesthesia, University College Hospital, Ibadan, Oyo State, Nigeria

Date of Submission12-Nov-2020
Date of Acceptance29-Jul-2021
Date of Web Publication17-Sep-2022

Correspondence Address:
Dr. Olusola K Idowu
Department of Anaesthesia, University College Hospital, Ibadan, Oyo State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kleuhsj.kleuhsj_393_20

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  Abstract 


CONTEXT: The safe practice of anesthesia encompasses professionalism, equipment, monitoring, medications, and conduct of anesthesia. Therefore, standard training is sine qua non to guarantee good surgical outcomes in a specialty associated with delicate and high-risk cases.
AIMS: The aims are to survey the work practices among anesthetist trainees from different centers across Nigeria.
SETTINGS AND DESIGN: A descriptive cross-sectional survey study conducted at the Department of Anaesthesia, University College Hospital, Ibadan, Nigeria.
SUBJECTS AND METHODS: Anesthetist trainees were administered structured questionnaires following informed consent.
STATISTICAL ANALYSIS USED: The Statistical Package for the Social Sciences (IBM SPSS version 23.0®) was used to analyze the obtained data. Results were presented using a frequency and percentage table, with a bar graph.
RESULTS: Out of the 76 respondents, there were 57 (75.0%) male and 19 (25.0%) female trainees who were mostly >30 years (90.8%). Mean residency duration was 1.4 ± 0.6 years, with many within 1–2 years of postgraduate training (67.1%). Many were junior registrars 71 (93.4%) and mostly (64.5%) work for >8 h. On clinical work practices, all the respondents reported that they always discuss the risks, purpose, and benefits of anesthesia (100.0%), 77.6% always discuss patient management with superior, 57.9% always provide postanesthetic care, and 88.2% always obtain informed consent. Only 6 out of the 13 anesthetic techniques listed had ≥50% positive responses with confirmation of their abilities to perform these techniques.
CONCLUSIONS: Most of the anesthetist trainees reported considerable abilities concerning clinical work practices in anesthesia. However, we observed significant limitations in the provisioning of some anesthetic techniques among many junior registrar trainees and this was not unexpected considering their current level of training.

Keywords: Anesthesia techniques, anesthesia training, clinical practices


How to cite this article:
Idowu OK, Osinaike BB. A survey study on self-reported practice and work environment among anesthetist trainees in Nigeria. Indian J Health Sci Biomed Res 2022;15:235-9

How to cite this URL:
Idowu OK, Osinaike BB. A survey study on self-reported practice and work environment among anesthetist trainees in Nigeria. Indian J Health Sci Biomed Res [serial online] 2022 [cited 2022 Sep 25];15:235-9. Available from: https://www.ijournalhs.org/text.asp?2022/15/3/235/356281




  Introduction Top


Anesthesia is an essential specialty requiring a high level of medical diagnostic knowledge, clinical expertise, and appropriate resources. Anesthetists are primarily physicians who administer anesthetic agents to relieve pain, assess patients during the preoperative period, suppress the consciousness of patients undergoing surgery, and provide life support functions during surgery at intraoperative and postoperative periods.[1],[2]

The standard practice of safe anesthesia encompasses professionalism, equipment and facilities, monitoring, medications, and intravenous fluids, and conduct of anesthesia. In a clinical setting, one of the successful conducts of surgical procedure is hinged on increased access to the use of safe anesthesia, and if proper checks are not in place, a single error can be costly and can lead to the death of patients.[3]

By default, anesthetists are expected to be trained on the scope of work practice and to garner skills during the course of training. It is expected that the practice of anesthesia should be conformed to universally recognized standards, however, it is observed that the practice and mode of delivery of anesthesia care vary from country to country due to many factors.[4] This was among the many reasons why the safety standard practice of anesthesia was developed by the World Federation of Societies of Anaesthesiologists to provide guidance and to improve the quality and safety of anesthesia care to anesthesia physicians, their professional organizations, hospitals, and governments due to the delicate and high-risk nature of the specialty, which warrants the application of standard methodologies and procedural training concerning patient outcome.[3]

In Nigeria, anesthesia training is primarily governed by the National Postgraduate Medical College of Nigeria (NPMCN) and the West African College of Surgeons (WACS).[5],[6] The standard guideline on anesthesia training by the NPMCN states that junior and senior registrars are expected to have obtained adequate knowledge and hands-on experience on several anesthetic techniques within 24 and 48 months of training, respectively.[5] Similarly to the WACS guidelines on anesthesia training, junior registrars are expected to be able to carry out some basic anesthetic techniques at the end of the first 36 months of training, while at the end of another 24 months, the trainees are expected to have garnered the skills required for all the forms of anesthetic procedures.[6]

This study was therefore carried out to survey the clinical work practices among anesthetist trainees from different centers across Nigeria.


  Subjects and Methods Top


Ethical approval was obtained from the University of Ibadan/University College Hospital Ethical Committee with application number UI/EC/20/0434 dated 05.11.20. A written informed consent was obtained from the respondents that participated in the study. This manuscript adheres to the applicable Strengthening the Reporting of Observational Studies in Epidemiology guidelines. This descriptive cross-sectional survey study was conducted during an update course attended by resident anesthetist trainees from 28 centers across Nigeria at the Department of Anaesthesia, University College Hospital, Ibadan, Nigeria in July 2019. The permission to carry out the research work was also granted by the Head of Anaesthesia Department.

A total of 94 anesthetist trainees were present. Using the online Stat Cal, a sample size of 76 was obtained with statistical power set to 95% confidence interval and 5% margin error. Following a homogenous purposive sampling technique, the questionnaires were self-administered with a recall period of 2–8 weeks. The survey comprised 4 different sections: Section A contained questions on respondent's characteristics, staff strength, hospital information on the number of cases, and time of work duration; Section B contained questions on the presence of some specific units such as Neurosurgery, Cardiothoracic, Intensive Care Unit (ICU), and high dependency unit (HDU); Section C contained questions on the clinical and work environment practices such as the presence of consultants during cases, provisioning of anesthesia care, discussing purpose, risk, and patient management with superiors; and Section D contained questions that asked about their abilities to perform some esthetic techniques such as subarachnoid block, epidural anesthesia, brachial plexus block, axillary block, and femoral block.

The data collected were coded and analyzed using the Statistical Package for Scientific Solutions (IBM SPSS version 23.0®). The variables were presented using a frequency and percentage table and with a bar graph where appropriate.


  Results Top


Out of the 76 analyzed questionnaires, 57 (75%) and 19 (25%) were male and female respondents, respectively. Majority 69 (90.8%) of the respondents had ages >30 years. There were 71 (93.4%) junior registrars and 5 (6.6%) senior registrars. Their current mean years of residency training were 1.4 ± 0.6 years and many 51 (67.1%) of the respondents were within 1–2 years of training. Many (64.5%) of the respondents worked for >8 h with a median number of 4 cases per day [Table 1]. More than three-quarters of the respondents were from accredited centers by both National Postgraduate College and WACS, while 15 (19.7%) and 2 (2.6%) of the respondents were from centers accredited by National Postgraduate College and WACS, respectively [Table 1]. The median (interquartile range [IQR]) number of available staff strength provided by the respondents was 2 (3) in medical officers, 8 (5) in registrars, 8 (4) in senior registrars, and 7 (5) in consultants. The median (IQR) number of daily cases was 4 (2) in all from the various centers [Table 1].
Table 1: Respondents' characteristics

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The mostly reported result on the available special unit within the various centres among the anaesthetist trainees was Neurosurgery unit 71 (93.4%), followed by Cardiothoracic unit 69 (90.8%), Intensive Care Unit (ICU) 74 (97.4%), and High Dependency Unit (HDU) 39 (51.3%) [Table 2].
Table 2: Special units within centers

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The respondents reported that close to one-fifth of consultants were always present during surgical cases. On some clinical work practices, more than four-fifths of the respondents stated that they always obtain informed consent from their patients, and over half of the respondents reported being able to provide postanesthetic care. About three-quarters of respondents also reported that they discuss patient management with their superiors. Furthermore, all the respondents discuss the purpose, risk, and benefits of anesthesia with their patients [Figure 1].
Figure 1: Clinical and environmental work practices

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In [Table 3], all the senior registrars were able to perform subarachnoid block, while only one of the junior registrars reported not being able to administer subarachnoid block. Other anesthetic techniques that can be administered as reported by the respondents included epidural anesthesia 70 (92.1%), brachial plexus block 22 (28.9%), axillary block 31 (40.8%), supra/infraclavicular block 13 (17.1%), interscalene block 11 (14.5%), femoral block 27 (35.5%), caudal block 52 (68.4%), Bier's block 42 (55.3%), ophthalmologic block 8 (10.5%), arterial cannula insertion 38 (50.0%), pulmonary artery catheter insertion 14 (18.4%), and venous pressure catheters 50 (65.8%). Overall, only 6 out of the 13 anesthetic techniques listed had ≥50% positive responses with confirmation of their abilities to perform these techniques. It was also observed that only junior registrars were unable to perform many of the anesthetic techniques.
Table 3: Anesthetic techniques

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  Discussion Top


In this survey study, it was observed that many of the anesthetist trainees were within their first 2 years of postgraduate training, and they reported considerable abilities concerning some of the clinical and environmental work practices in anesthesia.

In some developing countries, access to safe anesthesia is still very low.[7],[8] This contributes to the burdens faced with the health-care system with various noncommunicable diseases, infectious diseases, trauma-related and injuries.[9] The availability of several operational units within the hospital helps to provide adequate treatments for patients.[8],[10] From this study, many of the respondents reported having neurosurgery unit (93.4%), cardiothoracic unit (90.8%), and ICU (97.4%). However, a lower number of participants reported the presence of a HDU (51.3%) within their centers.

Early studies have observed the uneven distribution of resources and medical personnel occurrence in developing countries.[11] In underdeveloped and developing countries, the lack of adequate anesthetists and anesthesia-related services are among the major challenges of health-related delivery systems.[12] In this index study, the median reported staff strength included 2 medical officers, 8 junior registrars, 8 senior registrars, and 7 consultants. It was also observed that about 17.1% of the consultants were always available for every of their routine medical cases.

Jukic et al.[13] in their study on the knowledge and practices of obtaining informed consent for medical procedures among specialist physicians found out that many had no formal knowledge on informed consent and the procedural implementation of the processes. Furthermore, they observed internists and surgeons to be more informed than the anesthetists. However, this study observed that many (88.2%) of the respondents always obtain informed consents from their patients, which suggests that many understood the importance of obtaining informed consent before carrying out any medical procedure.

The role of anesthetists during postoperative care involves monitoring, diagnosing, and treating acute changes in organ function.[14] Following surgeries, patients are required to meet some discharge criteria from Phase 1 to Phase 2 before being discharged during postanesthesia care. These criteria are often based on the (modified) Aldrete score which includes circulation, consciousness, adequate activity, oxygen saturation, maintenance of respiration, normothermia, stable vital signs, adequate pain control, absence of nausea, maintenance of appropriate surgical site dressings, ambulation ability, etc.[15] In this study, 57.9% of the trainees reported being able to provide postanesthetic care. One of the reasons for this low knowledge of postanesthetic provisioning could be due to the current level of the junior registrars, which constituted the majority of the respondents. Furthermore, 77.6% of the respondents stated that they always discuss patient management with their superiors, and all the trainees stated that the purpose, risk, and benefits of anesthesia were always discussed with their patients.

The standard guideline provided by the NPMCN and WACS on anesthesia training has revealed that within 24 months and 36 months of training, respectively, the junior registrars are expected to have obtained adequate knowledge and hands-on experience on several anesthetic techniques.[5],[6] Furthermore, at the end of their trainings, it is expected that the trainees should have garnered the skills required for all the forms of anesthetic procedures.[6] These set of skills include knowing how to intubate, airway management, perform central neural/nerve blocks, cardiopulmonary resuscitation, trauma life support, etc.[5],[6] From this study, several anesthetic techniques such as blocks like subarachnoid, brachial plexus, axillary, supra/infraclavicular, interscalene, femoral, caudal, bier, and ophthalmologic block; catheterization such as in pulmonary artery and central venous pressure catheters was reported.

Regional anesthesia is one of the most preferred anesthetic techniques that are widely used to prevent airway-related complications but due to poor-resource settings, spinal anesthesia is used mostly during surgical cases.[16] In the study by Rukewe and Fatiregun,[17] on the use of regional anesthesia by anesthetists in Nigeria, they reported that 92.9%, 15%, and 2.9% of the anesthetists were able to carry out spinal, epidural, and peripheral nerve blocks, respectively. They also found out that 47.1% of the respondents had never performed a nerve block.[17] However, in this study, 98.7% of the trainees stated that they were able to perform subarachnoid block and 92.1% also stated that they were able to carry out epidural anesthesia. These results, therefore, suggest an improvement over the years concerning subarachnoid and epidural anesthesia procedures among the trainees.

Other anesthetic techniques such as brachial plexus, axillary, supra/infraclavicular, interscalene, femoral and ophthalmologic block, and pulmonary artery catheters had less than half of the anesthetist trainees who responded with ability to carry out these techniques. The inability to carry out these techniques was mainly found among the junior registrars. This outcome is understandable because the junior registrars constituted the majority of the respondents and many were still within their 1st and 2nd year of training. Furthermore, another reason for this might be as a result of the limited exposure to the use and availability of these techniques within the various centers.

The first observed limitation in this study is the relatively small number of participants who were involved in the study. Second, the predominance of junior registrars to senior registrars introduces a form of bias that could have affected the eventual outcomes. Third, this study was dependent on self-reported competency level which could be challenging to correlate with the assessment of their actual competency levels.


  Conclusions Top


Our findings revealed that most of the anesthetist trainees reported considerable abilities with some anesthetic techniques and some ethical clinical work practices such as the discussion of risks, purpose, and benefits of anesthesia; discussion of patient management with superior; provisioning of postanesthetic care; and obtainment of consent. Nevertheless, some of the trainees were still not able to perform some certain listed anesthetic techniques, especially peripheral nerve blocks, which could be as a result of their current postgraduate level of training.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Yamamoto S, Tanaka P, Madsen MV, Macario A. Comparing anesthesiology residency training structure and requirements in seven different countries on three continents. Cureus 2017;9:e1060.  Back to cited text no. 4
    
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West African College of Surgeons (WACS). Anaethesia. Available from: https://www.wacscoac.org/index.php/faculties/anaesthesia. [Last accessed on 2020 Mar 01].  Back to cited text no. 6
    
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Bainbridge D, Martin J, Arango M, Cheng D, Evidence-Based Peri-Operative Clinical Outcomes Research (EPiCOR) Group. Perioperative and anaesthetic-related mortality in developed and developing countries: A systematic review and meta-analysis. Lancet 2012;380:1075-81.  Back to cited text no. 7
    
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Bharati SJ, Chowdhury T, Gupta N, Schaller B, Cappellani RB, Maguire D. Anaesthesia in underdeveloped world: Present scenario and future challenges. Niger Med J 2014;55:1-8.  Back to cited text no. 9
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Cherian M, Choo S, Wilson I, Noel L, Sheikh M, Dayrit M, et al. Building and retaining the neglected anaesthesia health workforce: Is it crucial for health systems strengthening through primary health care? Bull World Health Organ 2010;88:637-9.  Back to cited text no. 12
    
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Jukic M, Kvolik S, Kardum G, Kozina S, Tomic Juraga A. Knowledge and practices of obtaining informed consent for medical procedures among specialist physicians: Questionnaire study in 6 Croatian hospitals. Croat Med J 2009;50:567-74.  Back to cited text no. 13
    
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