Research article
Open Access

Poor Learning In Operation Theatres Causing Brain Drain

Sara Sadiq[1], Muhammad Fazal Hussain Qureshi[1], Mahira Lakhani[1], Muzna Shah[1], Muhammad Hassan Ayub[1]

Institution: 1. Ziauddin University
Corresponding Author: Mr Muhammad Fazal Hussain Qureshi ([email protected])
Categories: Educational Strategies, Learning Outcomes/Competency, Students/Trainees, Teaching and Learning, Postgraduate (including Speciality Training)
Published Date: 12/06/2019

Abstract

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.

Keywords: Medical education; Learning environment; operation theatre; postgraduates.

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.

Table 1.The overall Mean STEEM scores for Gender differences.

SUBSCALES

Male

Female

p-Value

Trainees’ perception of their trainer and teacher (Q1-Q13)

25

63

0.300

Trainees’ perception of learning opportunities (Q14-Q24)

25

63

0.034

Trainees’ perception of atmosphere in the operating theatre (Q25-Q32)

25

63

0.064

Trainees’ perception of supervision, workload and support (Q33-Q40)

25

63

0.237

STEEM overall Global Score (Q1-Q40)

25

63

0.045

 

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.

Table 2. STEEM Reliability Scores.

Subscales

Mean

SD

CI

Cronbach’s α

Trainees’ perception of their trainer and teacher (Q1-Q13)

32

9.091

30.18-34.03

0.849

Trainees’ perception of learning opportunities (Q14-Q24)

30

3.457

28.98-30.45

-0.298

Trainees’ perception of atmosphere in the operating theatre (Q25-Q32)

24

4.704

22.74-24.74

0.531

Trainees’ perception of supervision, workload and support (Q33-Q40)

23

6.349

21.90-24.60

0.801

STEEM overall Global Score (Q1-Q40)

109

16.958

105.21-112.40

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.

Table 3. Comparison of reliability score of Aberdeen surgical trainees, Birmingham Medical Students, LNH trainees with PMC Nawabshah trainees.

SUBSCALES

Aberdeen Surgical trainees (Cassar, 2004)

STEEM Study of Birmingham (Nagraj, Wall and Jones, 2006)

STEEM Study of

Liaquat National

Hospital (Soomro, Rehman and Hussain, 2017)

Peoples Medical College (PMC), Nawabshah

Reliability

Mean

Reliability

Mean

Reliability

Mean

Reliability

Mean

Trainees’ perception of their trainer and teacher (Q1-Q13)

0.84

51

0.84

47

0.72

48

0.84

32

Trainees’ perception of learning opportunities (Q14-Q24)

0.59

37

0.54

35

0.96

37

-0.298

30

Trainees’ perception of atmosphere in the operating theatre (Q25-Q32)

0.57

30

0.69

29

0.96

26

0.53

24

Trainees’ perception of supervision, workload and support (Q33-Q40)

0.57

30

0.65

27

0.98

25

0.80

23

STEEM overall Global Score (Q1-Q40)

0.88

149

0.86

139

0.97

136

0.82

109

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.

Table 4. Mean and standard deviation for Individual Statements of the STEEM with statistical differences between the Perceptions of Male and Female Students.

S No

Statement

Mean ± SD

Gender

Mean ±SD

p-Value

1

My trainer has a pleasant personality.

2.08 ±1.306

Male

2.96 ±1.695

0.002

Female

1.73 ±0.919

2

I get on well with my trainer.

2.39 ±1.281

Male

2.88 ±1.616

0.074

Female

2.19 ±1.075

3

My trainer is enthusiastic about teaching.

2.28 ±1.304

Male

3 ±1.658

0.013

Female

2 ±1.016

4

My trainer has a genuine interest in my progress.

2.48 ±1.330

Male

3.16 ±1.491

0.004

Female

2.21 ±1.166

5

I understand what my trainer is trying to teach me.

2.41 ±1.353

Male

2.92 ±1.525

0.026

Female

2.21 ±1.233

6

My trainer's surgical skills are very good.

1.41 ±0.672

Male

1.52 ±0.510

0.047

Female

1.37 ±0.725

7

My trainer gives me time to practice surgical skills in theatre.

2.25 ±0.875

Male

1.68 ±0.476

0.000

Female

2.48 ±0.895

8

My trainer immediately takes the instruments away when I do not perform well.*

2.65 ±1.083

Male

3.36 ±1.075

0.000

Female

2.37 ±0.955

9

Before the operation my trainer discusses the surgical technique planned.

2.39 ±1.159

Male

2 ±0.707

0.167

Female

2.54 ±1.268

10

Before the operation my trainer discusses what parts of the procedure I will perform.

2.41 ±1.090

Male

2.04 ±0.676

0.095

Female

2.56 ±1.188

11

My trainer expects my surgical skills to be as good as his/hers.*

3.73 ±1.014

Male

3.60 ±0.866

0.325

Female

3.78 ±1.069

12

My trainer gives me feedback on my performance.

2.86 ±1.302

Male

3.04 ±1.744

0.675

Female

2.79 ±1.034

13

My trainer's criticism is constructive.

2.77 ±1.302

Male

3.28 ±1.429

0.044

Female

2.57 ±1.201

14

On this unit the type of operations are too complex for my level.*

3.44 ±1.355

Male

2.84 ±1.573

0.023

Female

3.68 ±1.189

15

The elective operating list has the right case mix to suit my training.

2.36 ±0.899

Male

2.56 ±0.917

0.124

Female

2.29 ±0.888

16

There are far too many cases on the elective list to give me the opportunity to operate.*

2.82 ±1.199

Male

2.76 ±1.508

0.746

Female

2.84 ±1.066

17

I get enough opportunity to assist.

2.56 ±1.355

Male

3.16 ±1.573

0.023

Female

2.32 ±1.189

18

There are enough theatre sessions per week for me to gain the appropriate experience.

2.81 ±1.445

Male

2.96 ±1.620

0.559

Female

2.75 ±1.379

19

More senior trainees take my opportunities to operate.*

3.08 ±1.042

Male

2.88 ±1.013

0.205

Female

3.16 ±1.050

20

The number of emergency procedures is sufficient for me to gain the appropriate experience.

2.70 ±1.146

Male

2.84 ±1.214

0.439

Female

2.65 ±1.124

21

The variety of emergency cases gives me the appropriate exposure.

2.22 ±0.964

Male

2.72 ±1.242

0.017

Female

2.02 ±0.751

22

My trainer is in too much of a rush during emergency cases to let me operate.*

2.40 ±1.000

Male

2.24 ±1.234

0.209

Female

2.46 ±0.895

23

I miss out on operative experience because of restrictions on working hours.*

3.05 ±1.212

Male

3.08 ±0.862

0.924

Female

3.03 ±1.332

24

I have the opportunity to develop the skills required at my stage.

2.28 ±1.212

Male

3.04 ±1.428

0.001

Female

1.98 ±0.975

25

The atmosphere in theatre is pleasant.

2.57 ±1.276

Male

3.32 ±1.134

0.001

Female

2.27 ±1.125

26

In theatre I don't like being corrected in front of medical students, nurses and residents.*

3.40 ±1.067

Male

3.56 ±0.821

0.456

Female

3.33 ±1.150

27

The nursing staff dislike it when I operate as the operation takes longer.*

3.56 ±1.355

Male

3.72 ±0.980

0.927

Female

3.49 ±1.480

28

The anaesthetists put pressure on my trainer to operate him/herself to reduce aesthetic time.*

3.84 ±1.123

Male

3.68 ±0.627

0.071

Female

3.90 ±1.266

29

The theatre staff are friendly.

2.57 ±1.153

Male

3.20 ±1.000

0.001

Female

2.32 ±1.119

30

I feel discriminated against in theatre because of my gender.*

2.83 ±1.366

Male

2.28 ±1.308

0.011

Female

3.05 ±1.337

31

I feel discriminated against in theatre because of my race.*

2.39 ±1.033

Male

2.04 ±1.136

0.017

Female

2.52 ±0.965

32

I feel part of a team in theatre.

2.59 ±1.310

Male

3.04 ±1.457

0.070

Female

2.41 ±1.213

33

I am too busy doing other work to go to theatre I am often too tired to get the most out of theatre teaching.*

3.09 ±1.002

Male

3.20 ±0.866

0.515

Female

3.05 ±1.054

34

I am often too tired to get the most out of theatre teaching.*

2.88 ±1.239

Male

2.80 ±1.155

0.699

Female

2.90 ±1.279

35

I am so stressed in theatre that I do not learn as much as I could.*

2.88 ±1.239

Male

2.80 ±1.155

0.699

Female

2.90 ±1.279

36

I am asked to perform operations alone that I do not feel competent.*

2.84 ±1.173

Male

2.52 ±1.085

0.063

Female

2.97 ±1.191

37

When I am in theatre, there is nobody to cover the ward.*

2.90 ±1.348

Male

3.20 ±1.225

0.116

Female

2.78 ±1.385

38

I get bleeped during operations (e.g. resolving ward issues during OT hours)*

2.90 ±1.348

Male

3.20 ±1.225

0.116

Female

2.78 ±1.385

39

The level of supervision in theatre is adequate for my level.

3.03 ±1.343

Male

3.24 ±1.451

0.244

Female

2.95 ±1.300

40

Theatre sessions are too long.*

2.74 ±1.077

Male

3.12 ±0.927

0.021

Female

2.59 ±1.102

* Statements for which reverse coding were done.

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 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 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.

Acknowledgements

None.

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Appendices

None.

Declarations

There are no conflicts of interest.
This has been published under Creative Commons "CC BY-SA 4.0" (https://creativecommons.org/licenses/by-sa/4.0/)

Ethics Statement

Approved by Ethical Review Commitee of Ziauddin University. Reference Number: 04200SSOT.

External Funding

This article has not had any External Funding

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The aim of the paper was to identify the perception of residents towards the learning environment in the surgical theatre of a medical school teaching hospital of interior Sindh, Pakistan.

The paper is interesting, but there are several things that need to be addressed:

• Too little information about the sample selection and questionnaire is given. The authors state only “Randomized sampling technique was used.” And then we are told that a total of 88 participants completed the questionnaire. We need to know the total population possible, the number of people identified (and approached) through the randomised sampling method (this will then lead the authors to calculate the response rate), how they were identified, whether or not there was any kind of stratification in the randomisation to ensure that all or most of the departments were represented, how the questionnaire was delivered (on paper and/or electronically (if electronically, details about the system used)), consent form, language of the consent form and questionnaire, etc.

• Similarly, in order to know how representative this sample was of the total population possible, it would be useful to know the male/female proportion and the departmental numbers. I realise that these could be sometimes fluid, but having 43% from one department and 1% from another could be good or bad, depending on the proportions of the population under study.

• Although the overall score of 115.44 vs 106.17 does show a difference, we do not know if that difference is statistically significant, as no p-value is given.

• Table 1 is supposed to give the overall Mean Scores for the questionnaire; instead, it gives the n-values for males and females.

• The Cronbach Alpha for Q14-Q24 is -0.298. The authors should comment on this.

• “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.” This is speculation. While some speculation is acceptable, it should at least be grounded in some evidence, and not simply a list of possible things that may or may not lead to lower scores in some situations.

• There is a problem in the relationship between the paper’s findings and the paper’s title (“Poor Learning In Operation Theatres Causing Brain Drain”). While the paper has shown that the environment is perceived by the residents as inadequate, the paper has not shown that:
o There is a brain drain, nor that
o The inadequate learning environment leads to poor learning, nor that
o This poor learning is causing, or even related to, a possible brain drain.
Until these have been established, the paper’s title needs to be quite significantly altered.

The paper could also benefit from a very careful proof-read. Sometimes the languages errors are minor irritations, but sometimes the sentences are either incomplete or are otherwise difficult to understand. For example, the first opening sentence begins “The educational environment is an important measure” and I have no idea what this means. Other errors such as lack of articles, “comparative statics” , long and somewhat seemingly rambling sentences, etc., make the paper very hard to read.

Minor
• The first time PMC is written as an abbreviation should be immediately after the words “Peoples Medical College”.
• Openepi should be written as OpenEpi, and it would be beneficial to give a link to the site.
• “Data was also analysed” should be “Data were also analysed”
• “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.” In the Results – this is a repetition of the information from Methods.
• P values below 0.001 should be written as <0.001 rather than 0.000, in spite of what the statistical package states.

So, this is an interesting study, but the authors need to pay closer attention to the details of the paper.


Possible Conflict of Interest:

For transparency, I am an Associate Editor of MedEdPublish. However I have posted this review as a member of the review panel with relevant expertise and so this review represents a personal, not institutional, opinion.

Isra Majeed - (17/06/2019)
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Thank you for contributing to the field of health. Will appreciate if the the appendices were included to allow duplication of this effort at one's own institution with any group of clinical learners. Very useful to promote qualitative research core to this type of education. Your conclusions are very on target. Your reference list is useful too.
Fatima Khawar - (16/06/2019)
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A very well written and explained article.
Rehana Faryal Mehdi - (13/06/2019)
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This is an excellent paper. Learning environment in operation theatre are equally important medical skills . It should be taught , nurtured and supported by all teachers.

So this paper is timely; it is well researched and written.

It is very educational for all teachers to note that these intrinsic skills have major positive outcome on patients ; they reduced morbidity and mortality. So we have no excuse not to teach and assess these skills
Lubna Jahanzeb - (12/06/2019)
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Bravo!! Unique yet important topic. This article seems to provide a deep insight of the learning conditions in Interior Sindh. Statistical analysis shows results in a way that it gives reader a clear idea on current situation and are very easy to understand. Methodology seems to be very elaborate. Introduction is self-explanatory but should include one or two more references. Language of article is very simple and easy to understand. Moreover being a teacher in Pakistan i had observed the same conditions in the area.
I would highly recommend this article and would encourage other to conduct more research in this area.