Most respondents from operating room teams in North-Central Nigeria had never heard of any NTS for surgery framework useful for variable resource contexts and only 8% had ever received any form of NTS training. Interprofessional teams identified communication and teamwork as the most deficient personal skills (38, 57%), and as the most needed for surgical team improvement (45, 67%). There was a very high demand for NTS training by all surgical team members motivated by expectations of improved patient safety and improved interprofessional team dynamics. Week-long, hybrid training courses (with combined in-person and online components) were the preferred format for delivery of NTS education. Factors that would facilitate attendance included a desire for patient safety and self-improvement, while barriers to attendance were conflicts of time, and training costs. The way forward for NTS training in North-Central Nigerian context is interprofessional training in hybrid format which prioritizes communication and teamwork, emphasizes patient safety, and is delivered at low costs.
There is very limited exposure to surgical-team centred NTS frameworks and training in Nigeria, and across West Africa. This is in contrast with the United Kingdom, North America, East Africa, Australasia, Europe, Japan, Malaysia and Sri Lanka, where NOTSS is taught regularly as an integral part of the surgical training programs and continuing medical education [20]. In the Nigerian context, there appears to be emphasis on technical skills over NTS. Over 2,500 Nigerian surgical specialists have been trained by the Nigeria Postgraduate Medical College of Nigeria (NPMCN) and the West African College of Surgeons (WACS), neither of which include structured NTS as a part of their curricula [21,22,23]. Nursing care training in the context also lacks emphasis on measurable, contextualized NTS [24]. Lack of exposure to these crucial interprofessional skills in regional medical education creates a significant gap in training and practice that needs to be addressed. While systems issues are a major challenge in this context, and much effort goes into handling surgical systems challenges like supply chain, human resources, surgical access, and surgical financing [25], this pragmatic emphasis can lead to a neglect of human factors and NTS. Our survey findings show that poor NTS have been identified as a challenge by interprofessional surgical teams, but training solutions have not yet been identified in the context.
Communication and teamwork were identified as the most important NTSs needed in the Nigerian surgical environment for personal development, team building, and improvement of patient care. The Nigerian health care scene has been a minefield of unhealthy interprofessional rivalry between cadres of health workers [26,27,28]. This has been responsible for a lack of cooperation, a sense of unwholesome hierarchy, mistrust, and fear that often carries itself into the operating room [27]. These age-old challenges have led to recurrent industrial actions, and counter-industrial actions, organizational tensions [26, 27, 29]. Respondents suggest prioritizing training in communication and teamwork over training in other cognitive aspects of NTS (situation awareness and decision making) as the way forward in the Nigerian context. The Nigerian healthcare system can potentially be enhanced with interprofessional education (IPE) and collaboration [30]. Early, multidisciplinary NTS training is a potential approach to addressing these aspects of the Nigerian surgical, and larger, medical practice space.
Longer-term training was suggested as the ideal format for NTS training in Nigeria. Designing NTS training courses to last for one week, as opposed to a few hours or 2–3 days was strongly suggested by respondents. This might reflect the recognition of the magnitude of exposure necessary to fill the gaps in NTS that have been identified in the context [26, 28]. Although financial incentives rank low as a facilitator, we cannot tell how much this might contribute to the desire for a longer training course. In this context where provider to patient ratio is significantly low [21], it will be challenging to ask clinical providers to leave their clinical duties for a one-week stretch for any type of training. Interval training of two to three days duration twice to thrice a year would be an acceptable compromise to meet provider expectations, while being sensitive to workload, and avoiding the fatigue of an extended course [31].
In-person training appears to have fallen out of favour with respondents as the majority (70.1%) preferred a hybrid approach. This is likely connected with lessons learned by the global community during the COVID-19 pandemic [32]. It is now accepted that high quality education and training can be carried out remotely, via online platforms. Strictly online courses introduce the challenge of wide internet bandwidth, high cost of internet data in Low- and Middle- Income Countries, and the challenges of online learning. The in-person component of blended courses will give the opportunity to include practical, non-didactic components like direct observation and evaluation of learners’ intraoperative NTS in a live operating space for a limited resource setting. Despite the availability of technology solutions including augmented reality, extended virtual reality, and machine learning, they are difficult to implement in a limited resource setting with poor quality internet [33]. Respondents see blended NTS courses as the way forward.
Highest priority barriers included the perioperative and institutional work environment (59.7%), and lack of funding to pay for NTS courses (20.9%). Other courses in Low- and Middle- Income Countries have identified similar barriers [34]. Surgical staff believed that NTS training would “clash with normal duties” or be limited by the “tight schedule of a residency training programme” or that they would not be released to attend trainings by their employers. This can be understood in the light of the low Surgeon Anaesthesia and Obstetrician specialist density in Nigeria (1.8 per 100,000), and the significant impact time away from work for development has on increasing the patient backlog [35]. Attending such courses can easily be seen as disruptions of patient care. Optimizing the work environment, and leadership buy-in are therefore key to preparing surgical staff for a NTS training in this context [36]. Setting up sponsored courses would also encourage engagement. Using mixed methods, Reis et al. found that lack of time, perception of overload at work, inadequate digital infrastructure or competence, and a variety of motivational and emotional elements were barriers to continuing medical education courses among primary care providers [37]. Our findings show that highest priority facilitators were essentially altruistic ideologies undergirding the motivation for NTS training. These include desire for improved patient safety, self-improvement, and improvements in work environment, as opposed to funding and financial incentives or the need for a certificate. Surgeons, anaesthesia providers, and perioperative nurses in the Nigerian context understand the priority of patient safety. Introduction of a multidisciplinary, interprofessional NTS curriculum that is sensitive to these felt needs is important for successful NOTSS-VRC training in this context. Preliminary results have been presented as an abstract at the American College of Surgeons Conference, 2022 [38].
