thesis of speaking skills

STUDENTS’ STRATEGIES IN DEVELOPING SPEAKING SKILL: A Study at a University in Bandung

Kusumayanthi, Susie (2011) STUDENTS’ STRATEGIES IN DEVELOPING SPEAKING SKILL: A Study at a University in Bandung. S2 thesis, Universitas Pendidikan Indonesia.

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This thesis reports on language learning strategies to develop speaking skill employed by university students. The students were categorized into high, middle, and low achiever students based on their English speaking proficiency. This thesis also reports on the reasons why these students employed the strategies. The study focuses on the above topics because the research concerning language learning strategies to develop speaking skill still receives a little attention in Indonesian EFL context. The employment of language learning strategies seems necessary for the language learners because speaking the new language often causes the greatest anxiety among other language skills (Oxford, 1996: 164). The students involved in this study were six university students who were studying at the eighth semester in a university in Bandung. They were taking a three-month English for Job Seekers Program supported by the university. In selecting the participants, this study made use of purposeful sampling to gain the important information from the participants (Alwasilah, 2002: 146). The instruments used were questionnaires and interviews. The questionnaires were Background Questionnaire and Strategy Inventory for Language Learning (SILL) Version7.0 developed by Oxford (1990); and the interview was open-ended questions interview. There were six language learning strategies in this study, namely: memory, cognitive, compensation, meta-cognitive, affective, and social strategies (Oxford, 1990). The data from the questionnaires were analyzed using Likkert scale; while the data from the interviews were analyzed using Kvale’s approach. The study then reveals several findings: (1) regarding the language learning strategies employed by the high, middle, and low achiever students in developing their speaking skills, the study figured out that the high and the low achiever students tended to employ meta-cognitive strategies the most for developing their speaking skills; while, the middle achiever students tended to employ affective strategies the most. The study also revealed interesting finding in which the high achiever students were using the widest variety of appropriate LLS. This might be one of the explanations why the high achiever students’ speaking skills were better than those of the middle and low achievers; (2) concerning the reasons why they employed certain strategies; the participants revealed that they employed certain strategies to effectively increase their ability in speaking. The reasons that were pointed out by the participants might indicate that they employed the language learning strategies consciously to assist their progress in developing English language skills, particularly speaking skills. As suggested by some researchers, among others Oxford (1996) and Wenden (1990), the conscious use of language learning strategies makes good language learners. It means that all of the participants in this study could be categorized as good language learners. The study also revealed that all of the participants have demonstrated their efforts to be able to speak English fluently by, among others, employing several strategies such as memory strategies, social strategies, compensation strategies as well as cognitive strategies. The employment of those strategies were in line with Harmer’s (2002: 269-271) theory concerning success in speaking fluently. Finally, based on the findings from the study, which may not be generalized to other settings, it is suggested that the language learning strategies be gradually but intensively introduced and implemented in developing English speaking skills.

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THESIS THE EFFECTIVENESS OF STORYTELLING TO INCREASE STUDENTS' SPEAKING SKILLS

2022, THE EFFECTIVENESS OF STORYTELLING TO INCREASE STUDENTS' SPEAKING SKILLS

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Jacqueline Maria Dias 1 ,
Muhammad Arsyad Subu 1 ,
Nabeel Al-Yateem 1 ,
Fatma Refaat Ahmed 1 ,
Syed Azizur Rahman 1 , 2 ,
Mini Sara Abraham 1 ,
Sareh Mirza Forootan 1 ,
Farzaneh Ahmad Sarkhosh 1 &
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BMC Nursing volume 23 , Article number: 322 ( 2024 ) Cite this article

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Metrics details

Understanding the stressors and coping strategies of nursing students in their first clinical training is important for improving student performance, helping students develop a professional identity and problem-solving skills, and improving the clinical teaching aspects of the curriculum in nursing programmes. While previous research have examined nurses’ sources of stress and coping styles in the Arab region, there is limited understanding of these stressors and coping strategies of nursing students within the UAE context thereby, highlighting the novelty and significance of the study.

A qualitative study was conducted using semi-structured interviews. Overall 30 students who were undergoing their first clinical placement in Year 2 at the University of Sharjah between May and June 2022 were recruited. All interviews were recorded and transcribed verbatim and analyzed for themes.

During their first clinical training, nursing students are exposed to stress from different sources, including the clinical environment, unfriendly clinical tutors, feelings of disconnection, multiple expectations of clinical staff and patients, and gaps between the curriculum of theory classes and labatories skills and students’ clinical experiences. We extracted three main themes that described students’ stress and use of coping strategies during clinical training: (1) managing expectations; (2) theory-practice gap; and (3) learning to cope. Learning to cope, included two subthemes: positive coping strategies and negative coping strategies.

Conclusions

This qualitative study sheds light from the students viewpoint about the intricate interplay between managing expectations, theory practice gap and learning to cope. Therefore, it is imperative for nursing faculty, clinical agencies and curriculum planners to ensure maximum learning in the clinical by recognizing the significance of the stressors encountered and help students develop positive coping strategies to manage the clinical stressors encountered. Further research is required look at the perspective of clinical stressors from clinical tutors who supervise students during their first clinical practicum.

Peer Review reports

Nursing education programmes aim to provide students with high-quality clinical learning experiences to ensure that nurses can provide safe, direct care to patients [ 1 ]. The nursing baccalaureate programme at the University of Sharjah is a four year program with 137 credits. The programmes has both theoretical and clinical components withs nine clinical courses spread over the four years The first clinical practicum which forms the basis of the study takes place in year 2 semester 2.

Clinical practice experience is an indispensable component of nursing education and links what students learn in the classroom and in skills laboratories to real-life clinical settings [ 2 , 3 , 4 ]. However, a gap exists between theory and practice as the curriculum in the classroom differs from nursing students’ experiences in the clinical nursing practicum [ 5 ]. Clinical nursing training places (or practicums, as they are commonly referred to), provide students with the necessary experiences to ensure that they become proficient in the delivery of patient care [ 6 ]. The clinical practicum takes place in an environment that combines numerous structural, psychological, emotional and organizational elements that influence student learning [ 7 ] and may affect the development of professional nursing competencies, such as compassion, communication and professional identity [ 8 ]. While clinical training is a major component of nursing education curricula, stress related to clinical training is common among students [ 9 ]. Furthermore, the nursing literature indicates that the first exposure to clinical learning is one of the most stressful experiences during undergraduate studies [ 8 , 10 ]. Thus, the clinical component of nursing education is considered more stressful than the theoretical component. Students often view clinical learning, where most learning takes place, as an unsupportive environment [ 11 ]. In addition, they note strained relationships between themselves and clinical preceptors and perceive that the negative attitudes of clinical staff produce stress [ 12 ].

The effects of stress on nursing students often involve a sense of uncertainty, uneasiness, or anxiety. The literature is replete with evidence that nursing students experience a variety of stressors during their clinical practicum, beginning with the first clinical rotation. Nursing is a complex profession that requires continuous interaction with a variety of individuals in a high-stress environment. Stress during clinical learning can have multiple negative consequences, including low academic achievement, elevated levels of burnout, and diminished personal well-being [ 13 , 14 ]. In addition, both theoretical and practical research has demonstrated that increased, continual exposure to stress leads to cognitive deficits, inability to concentrate, lack of memory or recall, misinterpretation of speech, and decreased learning capacity [ 15 ]. Furthermore, stress has been identified as a cause of attrition among nursing students [ 16 ].

Most sources of stress have been categorized as academic, clinical or personal. Each person copes with stress differently [ 17 ], and utilizes deliberate, planned, and psychological efforts to manage stressful demands [ 18 ]. Coping mechanisms are commonly termed adaptation strategies or coping skills. Labrague et al. [ 19 ] noted that students used critical coping strategies to handle stress and suggested that problem solving was the most common coping or adaptation mechanism used by nursing students. Nursing students’ coping strategies affect their physical and psychological well-being and the quality of nursing care they offer. Therefore, identifying the coping strategies that students use to manage stressors is important for early intervention [ 20 ].

Studies on nursing students’ coping strategies have been conducted in various countries. For example, Israeli nursing students were found to adopt a range of coping mechanisms, including talking to friends, engaging in sports, avoiding stress and sadness/misery, and consuming alcohol [ 21 ]. Other studies have examined stress levels among medical students in the Arab region. Chaabane et al. [ 15 ], conducted a systematic review of sudies in Arab countries, including Saudi Arabia, Egypt, Jordan, Iraq, Pakistan, Oman, Palestine and Bahrain, and reported that stress during clinical practicums was prevalent, although it could not be determined whether this was limited to the initial clinical course or occurred throughout clinical training. Stressors highlighted during the clinical period in the systematic review included assignments and workload during clinical practice, a feeling that the requirements of clinical practice exceeded students’ physical and emotional endurance and that their involvement in patient care was limited due to lack of experience. Furthermore, stress can have a direct effect on clinical performance, leading to mental disorders. Tung et al. [ 22 ], reported that the prevalence of depression among nursing students in Arab countries is 28%, which is almost six times greater than the rest of the world [ 22 ]. On the other hand, Saifan et al. [ 5 ], explored the theory-practice gap in the United Arab Emirates and found that clinical stressors could be decreased by preparing students better for clinical education with qualified clinical faculty and supportive preceptors.

The purpose of this study was to identify the stressors experienced by undergraduate nursing students in the United Arab Emirates during their first clinical training and the basic adaptation approaches or coping strategies they used. Recognizing or understanding different coping processes can inform the implementation of corrective measures when students experience clinical stress. The findings of this study may provide valuable information for nursing programmes, nurse educators, and clinical administrators to establish adaptive strategies to reduce stress among students going clinical practicums, particularly stressors from their first clinical training in different healthcare settings.

A qualitative approach was adopted to understand clinical stressors and coping strategies from the perspective of nurses’ lived experience. Qualitative content analysis was employed to obtain rich and detailed information from our qualitative data. Qualitative approaches seek to understand the phenomenon under study from the perspectives of individuals with lived experience [ 23 ]. Qualitative content analysis is an interpretive technique that examines the similarities and differences between and within different areas of text while focusing on the subject [ 24 ]. It is used to examine communication patterns in a repeatable and systematic way [ 25 ] and yields rich and detailed information on the topic under investigation [ 23 ]. It is a method of systematically coding and categorizing information and comprises a process of comprehending, interpreting, and conceptualizing the key meanings from qualitative data [ 26 ].

Setting and participants

This study was conducted after the clinical rotations ended in April 2022, between May and June in the nursing programme at the College of Health Sciences, University of Sharjah, in the United Arab Emirates. The study population comprised undergraduate nursing students who were undergoing their first clinical training and were recruited using purposive sampling. The inclusion criteria for this study were second-year nursing students in the first semester of clinical training who could speak English, were willing to participate in this research, and had no previous clinical work experience. The final sample consisted of 30 students.

Research instrument

The research instrument was a semi structured interview guide. The interview questions were based on an in-depth review of related literature. An intensive search included key words in Google Scholar, PubMed like the terms “nursing clinical stressors”, “nursing students”, and “coping mechanisms”. Once the questions were created, they were validated by two other faculty members who had relevant experience in mental health. A pilot test was conducted with five students and based on their feedback the following research questions, which were addressed in the study.

How would you describe your clinical experiences during your first clinical rotations?

In what ways did you find the first clinical rotation to be stressful?

What factors hindered your clinical training?

How did you cope with the stressors you encountered in clinical training?

Which strategies helped you cope with the clinical stressors you encountered?

Data collection

Semi-structured interviews were chosen as the method for data collection. Semi structured interviews are a well-established approach for gathering data in qualitative research and allow participants to discuss their views, experiences, attitudes, and beliefs in a positive environment [ 27 ]. This approach allows for flexibility in questioning thereby ensuring that key topics related to clinical learning stressors and coping strategies would be explored. Participants were given the opportunity to express their views, experiences, attitudes, and beliefs in a positive environment, encouraging open communication. These semi structured interviews were conducted by one member of the research team (MAS) who had a mental health background, and another member of the research team who attended the interviews as an observer (JMD). Neither of these researchers were involved in teaching the students during their clinical practicum, which helped to minimize bias. The interviews took place at the University of Sharjah, specifically in building M23, providing a familiar and comfortable environment for the participant. Before the interviews were all students who agreed to participate were provided with an explanation of the study’s purpose. The time and location of each interview were arranged. Before the interviews were conducted, all students who provided consent to participate received an explanation of the purpose of the study, and the time and place of each interview were arranged to accommodate the participants’ schedules and preferences. The interviews were conducted after the clinical rotation had ended in April, and after the final grades had been submitted to the coordinator. The timings of the interviews included the month of May and June which ensured that participants have completed their practicum experience and could reflect on the stressors more comprehensively. The interviews were audio-recorded with the participants’ consent, and each interview lasted 25–40 min. The data were collected until saturation was reached for 30 students. Memos and field notes were also recorded as part of the data collection process. These additional data allowed for triangulation to improve the credibility of the interpretations of the data [ 28 ]. Memos included the interviewers’ thoughts and interpretations about the interviews, the research process (including questions and gaps), and the analytic progress used for the research. Field notes were used to record the interviewers’ observations and reflections on the data. These additional data collection methods were important to guide the researchers in the interpretation of the data on the participants’ feelings, perspectives, experiences, attitudes, and beliefs. Finally, member checking was performed to ensure conformability.

Data analysis

The study used the content analysis method proposed by Graneheim and Lundman [ 24 ]. According to Graneheim and Lundman [ 24 ], content analysis is an interpretive technique that examines the similarities and differences between distinct parts of a text. This method allows researchers to determine exact theoretical and operational definitions of words, phrases, and symbols by elucidating their constituent properties [ 29 ]. First, we read the interview transcripts several times to reach an overall understanding of the data. All verbatim transcripts were read several times and discussed among all authors. We merged and used line-by-line coding of words, sentences, and paragraphs relevant to each other in terms of both the content and context of stressors and coping mechanisms. Next, we used data reduction to assess the relationships among themes using tables and diagrams to indicate conceptual patterns. Content related to stress encountered by students was extracted from the transcripts. In a separate document, we integrated and categorized all words and sentences that were related to each other in terms of both content and context. We analyzed all codes and units of meaning and compared them for similarities and differences in the context of this study. Furthermore, the emerging findings were discussed with other members of the researcher team. The final abstractions of meaningful subthemes into themes were discussed and agreed upon by the entire research team. This process resulted in the extraction of three main themes in addition to two subthemes related to stress and coping strategies.

Ethical considerations

The University of Sharjah Research Ethics Committee provided approval to conduct this study (Reference Number: REC 19-12-03-01-S). Before each interview, the goal and study procedures were explained to each participant, and written informed consent was obtained. The participants were informed that participation in the study was voluntary and that they could withdraw from the study at any time. In the event they wanted to withdraw from the study, all information related to the participant would be removed. No participant withdrew from the study. Furthermore, they were informed that their clinical practicum grade would not be affected by their participation in this study. We chose interview locations in Building M23that were private and quiet to ensure that the participants felt at ease and confident in verbalizing their opinions. No participant was paid directly for involvement in this study. In addition, participants were assured that their data would remain anonymous and confidential. Confidentiality means that the information provided by participants was kept private with restrictions on how and when data can be shared with others. The participants were informed that their information would not be duplicated or disseminated without their permission. Anonymity refers to the act of keeping people anonymous with respect to their participation in a research endeavor. No personal identifiers were used in this study, and each participant was assigned a random alpha-numeric code (e.g., P1 for participant 1). All digitally recorded interviews were downloaded to a secure computer protected by the principal investigator with a password. The researchers were the only people with access to the interview material (recordings and transcripts). All sensitive information and materials were kept secure in the principal researcher’s office at the University of Sharjah. The data will be maintained for five years after the study is completed, after which the material will be destroyed (the transcripts will be shredded, and the tapes will be demagnetized).

In total, 30 nursing students who were enrolled in the nursing programme at the Department of Nursing, College of Health Sciences, University of Sharjah, and who were undergoing their first clinical practicum participated in the study. Demographically, 80% ( n = 24) were females and 20% ( n = 6) were male participants. The majority (83%) of study participants ranged in age from 18 to 22 years. 20% ( n = 6) were UAE nationals, 53% ( n = 16) were from Gulf Cooperation Council countries, while 20% ( n = 6) hailed from Africa and 7% ( n = 2) were of South Asian descent. 67% of the respondents lived with their families while 33% lived in the hostel. (Table 1 )

Following the content analysis, we identified three main themes: (1) managing expectations, (2) theory-practice gap and 3)learning to cope. Learning to cope had two subthemes: positive coping strategies and negative coping strategies. An account of each theme is presented along with supporting excerpts for the identified themes. The identified themes provide valuable insight into the stressors encountered by students during their first clinical practicum. These themes will lead to targeted interventions and supportive mechanisms that can be built into the clinical training curriculum to support students during clinical practice.

Theme 1: managing expectations

In our examination of the stressors experienced by nursing students during their first clinical practicum and the coping strategies they employed, we identified the first theme as managing expectations.

The students encountered expectations from various parties, such as clinical staff, patients and patients’ relatives which they had to navigate. They attempted to fulfil their expectations as they progressed through training, which presented a source of stress. The students noted that the hospital staff and patients expected them to know how to perform a variety of tasks upon request, which made the students feel stressed and out of place if they did not know how to perform these tasks. Some participants noted that other nurses in the clinical unit did not allow them to participate in nursing procedures, which was considered an enormous impediment to clinical learning, as noted in the excerpt below:

“…Sometimes the nurses… They will not allow us to do some procedures or things during clinical. And sometimes the patients themselves don’t allow us to do procedures” (P5).

Some of the students noted that they felt they did not belong and felt like foreigners in the clinical unit. Excerpts from the students are presented in the following quotes;

“The clinical environment is so stressful. I don’t feel like I belong. There is too little time to build a rapport with hospital staff or the patient” (P22).

“… you ask the hospital staff for some guidance or the location of equipment, and they tell us to ask our clinical tutor …but she is not around … what should I do? It appears like we do not belong, and the sooner the shift is over, the better” (P18).

“The staff are unfriendly and expect too much from us students… I feel like I don’t belong, or I am wasting their (the hospital staff’s) time. I want to ask questions, but they have loads to do” (P26).

Other students were concerned about potential failure when working with patients during clinical training, which impacted their confidence. They were particularly afraid of failure when performing any clinical procedures.

“At the beginning, I was afraid to do procedures. I thought that maybe the patient would be hurt and that I would not be successful in doing it. I have low self-confidence in doing procedures” (P13).

The call bell rings, and I am told to answer Room No. XXX. The patient wants help to go to the toilet, but she has two IV lines. I don’t know how to transport the patient… should I take her on the wheelchair? My eyes glance around the room for a wheelchair. I am so confused …I tell the patient I will inform the sister at the nursing station. The relative in the room glares at me angrily … “you better hurry up”…Oh, I feel like I don’t belong, as I am not able to help the patient… how will I face the same patient again?” (P12).

Another major stressor mentioned in the narratives was related to communication and interactions with patients who spoke another language, so it was difficult to communicate.

“There was a challenge with my communication with the patients. Sometimes I have communication barriers because they (the patients) are of other nationalities. I had an experience with a patient [who was] Indian, and he couldn’t speak my language. I did not understand his language” (P9).

Thus, a variety of expectations from patients, relatives, hospital staff, and preceptors acted as sources of stress for students during their clinical training.

Theme 2: theory-practice gap

Theory-practice gaps have been identified in previous studies. In our study, there was complete dissonance between theory and actual clinical practice. The clinical procedures or practices nursing students were expected to perform differed from the theory they had covered in their university classes and skills lab. This was described as a theory–practice gap and often resulted in stress and confusion.

“For example …the procedures in the hospital are different. They are different from what we learned or from theory on campus. Or… the preceptors have different techniques than what we learned on campus. So, I was stress[ed] and confused about it” (P11).

Furthermore, some students reported that they did not feel that they received adequate briefing before going to clinical training. A related source of stress was overload because of the volume of clinical coursework and assignments in addition to clinical expectations. Additionally, the students reported that a lack of time and time management were major sources of stress in their first clinical training and impacted their ability to complete the required paperwork and assignments:

“…There is not enough time…also, time management at the hospital…for example, we start at seven a.m., and the handover takes 1 hour to finish. They (the nurses at the hospital) are very slow…They start with bed making and morning care like at 9.45 a.m. Then, we must fill [out] our assessment tool and the NCP (nursing care plan) at 10 a.m. So, 15 only minutes before going to our break. We (the students) cannot manage this time. This condition makes me and my friends very stressed out. -I cannot do my paperwork or assignments; no time, right?” (P10).

“Stressful. There is a lot of work to do in clinical. My experiences are not really good with this course. We have a lot of things to do, so many assignments and clinical procedures to complete” (P16).

The participants noted that the amount of required coursework and number of assignments also presented a challenge during their first clinical training and especially affected their opportunity to learn.

“I need to read the file, know about my patient’s condition and pathophysiology and the rationale for the medications the patient is receiving…These are big stressors for my learning. I think about assignments often. Like, we are just focusing on so many assignments and papers. We need to submit assessments and care plans for clinical cases. We focus our time to complete and finish the papers rather than doing the real clinical procedures, so we lose [the] chance to learn” (P25).

Another participant commented in a similar vein that there was not enough time to perform tasks related to clinical requirements during clinical placement.

“…there is a challenge because we do not have enough time. Always no time for us to submit papers, to complete assessment tools, and some nurses, they don’t help us. I think we need more time to get more experiences and do more procedures, reduce the paperwork that we have to submit. These are challenges …” (P14).

There were expectations that the students should be able to carry out their nursing duties without becoming ill or adversely affected. In addition, many students reported that the clinical environment was completely different from the skills laboratory at the college. Exposure to the clinical setting added to the theory-practice gap, and in some instances, the students fell ill.

One student made the following comment:

“I was assisting a doctor with a dressing, and the sight and smell from the oozing wound was too much for me. I was nauseated. As soon as the dressing was done, I ran to the bathroom and threw up. I asked myself… how will I survive the next 3 years of nursing?” (P14).

Theme 3: learning to cope

The study participants indicated that they used coping mechanisms (both positive and negative) to adapt to and manage the stressors in their first clinical practicum. Important strategies that were reportedly used to cope with stress were time management, good preparation for clinical practice, and positive thinking as well as engaging in physical activity and self-motivation.

“Time management. Yes, it is important. I was encouraging myself. I used time management and prepared myself before going to the clinical site. Also, eating good food like cereal…it helps me very much in the clinic” (P28).

“Oh yeah, for sure positive thinking. In the hospital, I always think positively. Then, after coming home, I get [to] rest and think about positive things that I can do. So, I will think something good [about] these things, and then I will be relieved of stress” (P21).

Other strategies commonly reported by the participants were managing their breathing (e.g., taking deep breaths, breathing slowly), taking breaks to relax, and talking with friends about the problems they encountered.

“I prefer to take deep breaths and breathe slowly and to have a cup of coffee and to talk to my friends about the case or the clinical preceptor and what made me sad so I will feel more relaxed” (P16).

“Maybe I will take my break so I feel relaxed and feel better. After clinical training, I go directly home and take a long shower, going over the day. I will not think about anything bad that happened that day. I just try to think about good things so that I forget the stress” (P27).

“Yes, my first clinical training was not easy. It was difficult and made me stressed out…. I felt that it was a very difficult time for me. I thought about leaving nursing” (P7).

I was not able to offer my prayers. For me, this was distressing because as a Muslim, I pray regularly. Now, my prayer time is pushed to the end of the shift” (P11).

“When I feel stress, I talk to my friends about the case and what made me stressed. Then I will feel more relaxed” (P26).

Self-support or self-motivation through positive self-talk was also used by the students to cope with stress.

“Yes, it is difficult in the first clinical training. When I am stress[ed], I go to the bathroom and stand in the front of the mirror; I talk to myself, and I say, “You can do it,” “you are a great student.” I motivate myself: “You can do it”… Then, I just take breaths slowly several times. This is better than shouting or crying because it makes me tired” (P11).

Other participants used physical activity to manage their stress.

“How do I cope with my stress? Actually, when I get stressed, I will go for a walk on campus” (P4).

“At home, I will go to my room and close the door and start doing my exercises. After that, I feel the negative energy goes out, then I start to calm down… and begin my clinical assignments” (P21).

Both positive and negative coping strategies were utilized by the students. Some participants described using negative coping strategies when they encountered stress during their clinical practice. These negative coping strategies included becoming irritable and angry, eating too much food, drinking too much coffee, and smoking cigarettes.

“…Negative adaptation? Maybe coping. If I am stressed, I get so angry easily. I am irritable all day also…It is negative energy, right? Then, at home, I am also angry. After that, it is good to be alone to think about my problems” (P12).

“Yeah, if I…feel stress or depressed, I will eat a lot of food. Yeah, ineffective, like I will be eating a lot, drinking coffee. Like I said, effective, like I will prepare myself and do breathing, ineffective, I will eat a lot of snacks in between my free time. This is the bad side” (P16).

“…During the first clinical practice? Yes, it was a difficult experience for us…not only me. When stressed, during a break at the hospital, I will drink two or three cups of coffee… Also, I smoke cigarettes… A lot. I can drink six cups [of coffee] a day when I am stressed. After drinking coffee, I feel more relaxed, I finish everything (food) in the refrigerator or whatever I have in the pantry, like chocolates, chips, etc” (P23).

These supporting excerpts for each theme and the analysis offers valuable insights into the specific stressors faced by nursing students during their first clinical practicum. These insights will form the basis for the development of targeted interventions and supportive mechanisms within the clinical training curriculum to better support students’ adjustment and well-being during clinical practice.

Our study identified the stressors students encounter in their first clinical practicum and the coping strategies, both positive and negative, that they employed. Although this study emphasizes the importance of clinical training to prepare nursing students to practice as nurses, it also demonstrates the correlation between stressors and coping strategies.The content analysis of the first theme, managing expectations, paves the way for clinical agencies to realize that the students of today will be the nurses of tomorrow. It is important to provide a welcoming environment where students can develop their identities and learn effectively. Additionally, clinical staff should foster an environment of individualized learning while also assisting students in gaining confidence and competence in their repertoire of nursing skills, including critical thinking, problem solving and communication skills [ 8 , 15 , 19 , 30 ]. Another challenge encountered by the students in our study was that they were prevented from participating in clinical procedures by some nurses or patients. This finding is consistent with previous studies reporting that key challenges for students in clinical learning include a lack of clinical support and poor attitudes among clinical staff and instructors [ 31 ]. Clinical staff with positive attitudes have a positive impact on students’ learning in clinical settings [ 32 ]. The presence, supervision, and guidance of clinical instructors and the assistance of clinical staff are essential motivating components in the clinical learning process and offer positive reinforcement [ 30 , 33 , 34 ]. Conversely, an unsupportive learning environment combined with unwelcoming clinical staff and a lack of sense of belonging negatively impact students’ clinical learning [ 35 ].

The sources of stress identified in this study were consistent with common sources of stress in clinical training reported in previous studies, including the attitudes of some staff, students’ status in their clinical placement and educational factors. Nursing students’ inexperience in the clinical setting and lack of social and emotional experience also resulted in stress and psychological difficulties [ 36 ]. Bhurtun et al. [ 33 ] noted that nursing staff are a major source of stress for students because the students feel like they are constantly being watched and evaluated.

We also found that students were concerned about potential failure when working with patients during their clinical training. Their fear of failure when performing clinical procedures may be attributable to low self-confidence. Previous studies have noted that students were concerned about injuring patients, being blamed or chastised, and failing examinations [ 37 , 38 ]. This was described as feeling “powerless” in a previous study [ 7 , 12 ]. In addition, patients’ attitudes towards “rejecting” nursing students or patients’ refusal of their help were sources of stress among the students in our study and affected their self-confidence. Self-confidence and a sense of belonging are important for nurses’ personal and professional identity, and low self-confidence is a problem for nursing students in clinical learning [ 8 , 39 , 40 ]. Our findings are consistent with a previous study that reported that a lack of self-confidence was a primary source of worry and anxiety for nursing students and affected their communication and intention to leave nursing [ 41 ].

In the second theme, our study suggests that students encounter a theory-practice gap in clinical settings, which creates confusion and presents an additional stressors. Theoretical and clinical training are complementary elements of nursing education [ 40 ], and this combination enables students to gain the knowledge, skills, and attitudes necessary to provide nursing care. This is consistent with the findings of a previous study that reported that inconsistencies between theoretical knowledge and practical experience presented a primary obstacle to the learning process in the clinical context [ 42 ], causing students to lose confidence and become anxious [ 43 ]. Additionally, the second theme, the theory-practice gap, authenticates Safian et al.’s [ 5 ] study of the theory-practice gap that exists United Arab Emirates among nursing students as well as the need for more supportive clinical faculty and the extension of clinical hours. The need for better time availability and time management to complete clinical tasks were also reported by the students in the study. Students indicated that they had insufficient time to complete clinical activities because of the volume of coursework and assignments. Our findings support those of Chaabane et al. [ 15 ]. A study conducted in Saudi Arabia [ 44 ] found that assignments and workload were among the greatest sources of stress for students in clinical settings. Effective time management skills have been linked to academic achievement, stress reduction, increased creativity [ 45 ], and student satisfaction [ 46 ]. Our findings are also consistent with previous studies that reported that a common source of stress among first-year students was the increased classroom workload [ 19 , 47 ]. As clinical assignments and workloads are major stressors for nursing students, it is important to promote activities to help them manage these assignments [ 48 ].

Another major challenge reported by the participants was related to communicating and interacting with other nurses and patients. The UAE nursing workforce and population are largely expatriate and diverse and have different cultural and linguistic backgrounds. Therefore, student nurses encounter difficulty in communication [ 49 ]. This cultural diversity that students encounter in communication with patients during clinical training needs to be addressed by curriculum planners through the offering of language courses and courses on cultural diversity [ 50 ].

Regarding the third and final theme, nursing students in clinical training are unable to avoid stressors and must learn to cope with or adapt to them. Previous research has reported a link between stressors and the coping mechanisms used by nursing students [ 51 , 52 , 53 ]. In particular, the inability to manage stress influences nurses’ performance, physical and mental health, attitude, and role satisfaction [ 54 ]. One such study suggested that nursing students commonly use problem-focused (dealing with the problem), emotion-focused (regulating emotion), and dysfunctional (e.g., venting emotions) stress coping mechanisms to alleviate stress during clinical training [ 15 ]. Labrague et al. [ 51 ] highlighted that nursing students use both active and passive coping techniques to manage stress. The pattern of clinical stress has been observed in several countries worldwide. The current study found that first-year students experienced stress during their first clinical training [ 35 , 41 , 55 ]. The stressors they encountered impacted their overall health and disrupted their clinical learning. Chaabane et al. [ 15 ] reported moderate and high stress levels among nursing students in Bahrain, Egypt, Iraq, Jordan, Oman, Pakistan, Palestine, Saudi Arabia, and Sudan. Another study from Bahrain reported that all nursing students experienced moderate to severe stress in their first clinical placement [ 56 ]. Similarly, nursing students in Spain experienced a moderate level of stress, and this stress was significantly correlated with anxiety [ 30 ]. Therefore, it is imperative that pastoral systems at the university address students’ stress and mental health so that it does not affect their clinical performance. Faculty need to utilize evidence-based interventions to support students so that anxiety-producing situations and attrition are minimized.

In our study, students reported a variety of positive and negative coping mechanisms and strategies they used when they experienced stress during their clinical practice. Positive coping strategies included time management, positive thinking, self-support/motivation, breathing, taking breaks, talking with friends, and physical activity. These findings are consistent with those of a previous study in which healthy coping mechanisms used by students included effective time management, social support, positive reappraisal, and participation in leisure activities [ 57 ]. Our study found that relaxing and talking with friends were stress management strategies commonly used by students. Communication with friends to cope with stress may be considered social support. A previous study also reported that people seek social support to cope with stress [ 58 ]. Some students in our study used physical activity to cope with stress, consistent with the findings of previous research. Stretching exercises can be used to counteract the poor posture and positioning associated with stress and to assist in reducing physical tension. Promoting such exercise among nursing students may assist them in coping with stress in their clinical training [ 59 ].

Our study also showed that when students felt stressed, some adopted negative coping strategies, such as showing anger/irritability, engaging in unhealthy eating habits (e.g., consumption of too much food or coffee), or smoking cigarettes. Previous studies have reported that high levels of perceived stress affect eating habits [ 60 ] and are linked to poor diet quality, increased snacking, and low fruit intake [ 61 ]. Stress in clinical settings has also been linked to sleep problems, substance misuse, and high-risk behaviors’ and plays a major role in student’s decision to continue in their programme.

Implications of the study

The implications of the study results can be grouped at multiple levels including; clinical, educational, and organizational level. A comprehensive approach to addressing the stressors encountered by nursing students during their clinical practicum can be overcome by offering some practical strategies to address the stressors faced by nursing students during their clinical practicum. By integrating study findings into curriculum planning, mentorship programs, and organizational support structures, a supportive and nurturing environment that enhances students’ learning, resilience, and overall success can be envisioned.

Clinical level

Introducing simulation in the skills lab with standardized patients and the use of moulage to demonstrate wounds, ostomies, and purulent dressings enhances students’ practical skills and prepares them for real-world clinical scenarios. Organizing orientation days at clinical facilities helps familiarize students with the clinical environment, identify potential stressors, and introduce interventions to enhance professionalism, social skills, and coping abilities Furthermore, creating a WhatsApp group facilitates communication and collaboration among hospital staff, clinical tutors, nursing faculty, and students, enabling immediate support and problem-solving for clinical situations as they arise, Moreover, involving chief nursing officers of clinical facilities in the Nursing Advisory Group at the Department of Nursing promotes collaboration between academia and clinical practice, ensuring alignment between educational objectives and the needs of the clinical setting [ 62 ].

Educational level

Sharing study findings at conferences (we presented the results of this study at Sigma Theta Tau International in July 2023 in Abu Dhabi, UAE) and journal clubs disseminates knowledge and best practices among educators and clinicians, promoting awareness and implementation of measures to improve students’ learning experiences. Additionally we hold mentorship training sessions annually in January and so we shared with the clinical mentors and preceptors the findings of this study so that they proactively they are equipped with strategies to support students’ coping with stressors during clinical placements.

Organizational level

At the organizational we relooked at the available student support structures, including counseling, faculty advising, and career advice, throughout the nursing program emphasizing the importance of holistic support for students’ well-being and academic success as well as retention in the nursing program. Also, offering language courses as electives recognizes the value of communication skills in nursing practice and provides opportunities for personal and professional development.

For first-year nursing students, clinical stressors are inevitable and must be given proper attention. Recognizing nursing students’ perspectives on the challenges and stressors experienced in clinical training is the first step in overcoming these challenges. In nursing schools, providing an optimal clinical environment as well as increasing supervision and evaluation of students’ practices should be emphasized. Our findings demonstrate that first-year nursing students are exposed to a variety of different stressors. Identifying the stressors, pressures, and obstacles that first-year students encounter in the clinical setting can assist nursing educators in resolving these issues and can contribute to students’ professional development and survival to allow them to remain in the profession. To overcome stressors, students frequently employ problem-solving approaches or coping mechanisms. The majority of nursing students report stress at different levels and use a variety of positive and negative coping techniques to manage stress.

The present results may not be generalizable to other nursing institutions because this study used a purposive sample along with a qualitative approach and was limited to one university in the Middle East. Furthermore, the students self-reported their stress and its causes, which may have introduced reporting bias. The students may also have over or underreported stress or coping mechanisms because of fear of repercussions or personal reasons, even though the confidentiality of their data was ensured. Further studies are needed to evaluate student stressors and coping now that measures have been introduced to support students. Time will tell if these strategies are being used effectively by both students and clinical personnel or if they need to be readdressed. Finally, we need to explore the perceptions of clinical faculty towards supervising students in their first clinical practicum so that clinical stressors can be handled effectively.

Data availability

The data sets are available with the corresponding author upon reasonable request.

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The authors are grateful to all second year nursing students who voluntarily participated in the study.

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JMD conceptualized the idea and designed the methodology, formal analysis, writing original draft and project supervision and mentoring. MAS prepared the methodology and conducted the qualitative interviews and analyzed the methodology and writing of original draft and project supervision. NY, FRA, SAR, MSA writing review and revising the draft. SMF, FAS, FJ worked with MAS on the formal analysis and prepared the first draft.All authors reviewed the final manuscipt of the article.

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Dias, J.M., Subu, M.A., Al-Yateem, N. et al. Nursing students’ stressors and coping strategies during their first clinical training: a qualitative study in the United Arab Emirates. BMC Nurs 23 , 322 (2024). https://doi.org/10.1186/s12912-024-01962-5

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6 Negotiation Skills All Professionals Can Benefit From

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11 May 2023

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Negotiation Skills

1. communication.

To achieve your ideal outcome at the bargaining table, it’s essential to clearly communicate what you’re hoping to walk away with and where your boundaries lie.

Effective negotiators develop communication skills that allow them to engage in civil discussion and work toward an agreeable solution.

Deal-making requires give and take; it’s critical to articulate your thoughts and actively listen to others’ ideas and needs. Not doing so can cause you to overlook key components of negotiations and leave them dissatisfied.

2. Emotional Intelligence

For better or worse, emotions play a role in negotiation, and you can use them to your advantage.

For example, positive emotions can increase feelings of trust at the bargaining table. Similarly, you can channel anxiety or nervousness into excitement.

You need a high degree of emotional intelligence to read other parties’ emotions. This can enable you to pick up on what they’re implying rather than explicitly stating and advantageously manage and use your emotions.

Related: The Impact of Emotions in Negotiation

3. Planning

Planning ahead with a clear idea of what you hope to achieve and where your boundaries lie is essential to any negotiation. Without adequate preparation, you can overlook important terms of your deal or alternative solutions.

First, consider the zone of possible agreement (ZOPA) . Sometimes called the bargaining zone, ZOPA is the range in which you and other parties can find common ground. A positive bargaining zone exists when the terms you’re willing to agree to overlap. A negative one exists when they don’t.

Next, it’s beneficial to understand your best alternative to a negotiated agreement (BATNA). If your discussion lands in a negative bargaining zone, your BATNA is the course of action you’ll take if the negotiation is unsuccessful. Knowing your BATNA can ensure you have a backup plan if you can’t reach an agreement. It can also help you avoid leaving the table empty-handed.

Negotiation Mastery | Earn your seat at the negotiation table | Learn More

4. Value Creation

Value creation is one of the key skills you should add to your negotiation toolkit.

To illustrate its importance, consider this analogy: When participating in a negotiation, you and the other parties typically try to obtain the biggest “slice of the pie” possible. Vying to maximize your slice inherently means someone will get a smaller piece.

To avoid this, shift your goals from growing your slice to expanding the whole pie. The benefits of doing so are twofold: First, you can realize greater value; second, you can establish a sense of rapport and trust that benefits future discussions.

5. Strategy

In addition to thorough preparation and the ability to create value, you need a clear understanding of effective negotiation tactics . By knowing what works and what doesn’t, you can tailor your strategy for every negotiation.

To develop a strong negotiation strategy , take the following steps:

Define your role
Understand your value
Consider your counterpart’s vantage point
Check in with yourself

Graphic showing the four steps to develop a negotiation strategy: define your role, understand your value, consider your counterpart's vantage point, and check in with yourself

Following this process can enable you to formulate a clear plan for the bargaining table. By understanding the roles of those involved, the value they offer, and their advantages, you can work toward a common goal. Checking in with yourself throughout the negotiation can also ensure you stay on the path to success.

6. Reflection

Finally, to round out your negotiation skills and develop your proficiency, reflect on past negotiations and identify areas for improvement.

After each negotiation—successful or not—think about what went well and what could have gone better. Doing so can allow you to evaluate the tactics that worked in your favor and those that fell short.

Next, identify areas you want to work on and create a plan of action. For example, if you had trouble aligning your goals with your counterpart’s, review concepts like ZOPA and BATNA. If your negotiations often leave you dissatisfied, learn new ways to create value.

How to Become a More Effective Leader | Access Your Free E-Book | Download Now

How to Negotiate Professionally

No matter your strengths and weaknesses, practice is a surefire way to develop your skills. The more you negotiate, the more prepared you’ll be in the future.

Structured learning opportunities can be highly beneficial. Negotiation books and articles are effective starting points for learning deal-making basics. Those that explore real-life examples of successful negotiations can provide perspective on how others navigated difficult discussions and approached conflict resolution.

Another option is to take an online course, such as Negotiation Mastery . In addition to learning from real experts—including public officials, executives, and military officers—you can participate in interactive negotiation simulations that allow you to apply your knowledge and develop your skills. You can also gain insight into negotiation’s emotional aspects and learn how to conduct an after-action review to inform future dealings.

Do you want to hone your bargaining skills? Explore our online course Negotiation Mastery and download our free leadership e-book to discover how you can become a more effective deal-maker.

This post was updated and republished on May 11, 2023. It was originally published on Sept. 2, 2021.

About the Author

Open access
Published: 16 May 2024

Non-technical skills training for Nigerian interprofessional surgical teams: a cross-sectional survey

Barnabas Tobi Alayande 1 , 2 , 3 , 4 ,
Callum Forbes 1 , 3 ,
Paul Kingpriest 4 ,
Adeyinka Adejumo 5 ,
Wendy Williams 6 ,
Felix Wina 7 ,
Christian Agbo Agbo 8 ,
Bamidele Omolabake 8 ,
Abebe Bekele 1 ,
Bashiru O Ismaila 2 ,
Fiona Kerray 9 ,
Augustine Sule 2 ,
Egide Abahuje 10 , 11 ,
Jamie M. Robertson 12 ,
The Non-technical Skills for Surgery Nigeria Group ,
Steven Yule 9 na1 ,
Robert Riviello 1 , 3 , 6 , 12 na1 &
Mercy Isichei 2 , 13 na1

BMC Medical Education volume 24 , Article number: 547 ( 2024 ) Cite this article

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Introduction

Non-technical skills (NTS) including communication, teamwork, leadership, situational awareness, and decision making, are essential for enhancing surgical safety. Often perceived as tangential soft skills, NTS are many times not included in formal medical education curricula or continuing medical professional development. We aimed to explore exposure of interprofessional teams in North-Central Nigeria to NTS and ascertain perceived facilitators and barriers to interprofessional training in these skills to enhance surgical safety and inform design of a relevant contextualized curriculum.

Six health facilities characterised by high surgical volumes in Nigeria’s North-Central geopolitical zone were purposively identified. Federal, state, and private university teaching hospitals, non-teaching public and private hospitals, and a not-for-profit health facility were included. A nineteen-item, web-based, cross-sectional survey was distributed to 71 surgical providers, operating room nurses, and anaesthesia providers by snowball sampling through interprofessional surgical team leads from August to November 2021. Data were analysed using Fisher’s exact test, proportions, and constant comparative methods for free text responses.

Respondents included 17 anaesthesia providers, 21 perioperative nurses, and 29 surgeons and surgical trainees, with a 95.7% survey completion rate. Over 96% 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 (64, 96%). The main motivations for training were expectations of resultant 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.

Conclusions

Interprofessional surgical teams in the Nigerian context have a high degree of interest in NTS training, and believe it can improve team dynamics, personal performance, and ultimately patient safety. Implementation of NTS training programs should emphasize interprofessional communication and teamworking.

Peer Review reports

Non-technical skills (NTS) are defined as a constellation of cognitive and social skills, demonstrated by teams and individuals, needed to reduce error, and to improve human performance in complex systems [ 1 ]. Derived originally from high-risk industries like aviation, aerospace, nuclear, explosive, military, and high-speed sports, these skills are essential in surgical care [ 2 ]. These skills can enhance the way surgical teams carry out surgery [ 1 ].

Failure of NTS such as situation awareness, decision making, leadership, communication and teamwork has been shown to contribute to up to half of all intra-operative errors [ 3 ]. Often considered soft skills, these competencies are many times overlooked in both formal and informal clinical training - particularly in low resource contexts where emphasis is placed on technical skills [ 4 ]. However, published literature shows that failure of NTS is a significant cause of adverse events in over 50% of all fatal medical accidents [ 5 ]. The consequence of not teaching NTS is at the heart of errors, sentinel events and near misses compromising a patient safety culture [ 6 ].

In addressing the absence of reliable ways to teach NTS, the Royal College of Surgeons, Edinburgh, and the University of Aberdeen developed the Non-Technical Skills for Surgeons (NOTSS) framework [ 1 ]. NOTSS refers to a behaviour rating tool grounded in a skills taxonomy that permits a valid and reliable observation and assessment of situation awareness, decision making, leadership, communication, and teamwork [ 7 ]. Considered by some as the gold standard for NTS, NOTSS has been extensively used across the world to prevent or mitigate surgical errors [ 8 ].

Even though up to 76 different published tools have been used to measure NTS in seven distinct areas of clinical practice, NTS training has been largely restricted to the high-income context [ 8 , 9 ]. Through a mixed methods approach involving Rwandan surgeons, anaesthetists, and nurses, the NOTSS behaviour rating system was modified for use in a variable resource context [ 4 ]. Non-Technical Skills for Surgery in Variable Resource Context (NOTSS-VRC) is targeted to address variability in resources, staff, systems support, and language frequently encountered by surgical teams in low- and middle-income countries [ 10 ]. The key modifications in NOTSS-VRC have been in the inclusion of contextual indicative behaviours that address this variability [ 4 , 10 , 11 ]. Other NTS courses have been designed for low-resource settings such as the Vital Anaesthesia Simulation Training (VAST) and SAFE Operating Room Course [ 12 , 13 , 14 ].

Although Nigeria and Rwanda are both sub-Saharan African countries and share some commonalities, they are different in regional location (West versus East Africa), working languages of healthcare teams, health system organization, specific kinds of resource variability, and availability of NTS training. Currently, there is no identified programme holistically offering training or continuing medical education using this framework for surgery, obstetrics, trauma, anaesthesia, or nursing in West Africa. This survey was designed to gather input from health professionals and trainees working in North-Central Nigeria on the need for NTS for surgery specific to surgeons, perioperative nurses, and anaesthetists.

Before modifying or implementing any NTS training program, it is important to assess the interest, preparedness, and training preferences of the local Nigerian workforce. A bespoke survey was developed to evaluate this by our multidisciplinary group of local researchers collaborating with the NOTSS global team consisting of clinical educators, surgeons, anaesthetists, a clinical psychologist, nurses, and surgical safety and human factors trainees [ 11 ]. A well-designed NTS program should be highly contextualized and meet the needs of the target healthcare workers [ 15 ]. The focus of the survey was to identify trained surgical providers’ current exposure to NTS and highlight the perceived needs and preferences of local surgical teams to guide the design of training modules on NTS for the Nigerian variable resource context.

The survey design adhered to the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) [ 16 ]. It was primarily a quantitative survey with a section for qualitative written responses. The voluntary survey was designed by a local team of surgical providers with training in NOTSS-VRC from Rwanda. Mentorship for the design was provided by the multidisciplinary and trans-sectoral NOTSS Global team. The survey was targeted at the 133 surgical providers, anaesthesia providers, and perioperative nurses working within six purposively selected institutions in North-Central Nigeria, spanning a wide variety of facility type and governance. These facilities included a non-profit secondary facility with focus on HIV-related surgical care, a private tertiary health facility, a specialist hospital, a state government-owned teaching hospital, a non-teaching federal medical centre, and a federal government-owned teaching hospital. These facilities were selected for their high surgical volumes and the presence of a multidisciplinary and interprofessional surgical team. Using a 95% confidence interval and an 8% margin of error, a representative sample of 71 out of 133 was selected through a convenience, stratified snowball technique at each institution, starting from the head of surgery, the lead perioperative nurse, or the lead anaesthesia provider. We elected to use convenience sampling to select surgical team leads based on their accessibility and availability to the researchers. Rather than being drawn at random from a larger population, in this strategy, participants were picked because they are easily available to the research team and would be able to influence propagation of the survey as leaders. We then stratified these leaders by their speciality into nursing team leads, surgical heads of department, and anaesthesia heads of department so that all cadres within the operating room are represented. The rational for the stratified snowball method was that these leaders would be able to identify and connect us to their peers who worked in interprofessional teams at the selected hospitals more effectively.

Ethical clearance for the NTS study was obtained from the Jos University Teaching Hospital, Nigeria Institutional Review Board (JUTH/DCS/IREC/127/XXXI/2277). Informed consent was obtained from participants prior to taking the approximately 7-minute survey. Participants were informed of the purpose of the survey, introduced to the primary investigator, and told the approximate length of time needed to fill the survey prior to consent. The survey consisted of close-ended questions (for quantitative analysis) and a free text response component (for qualitative analysis). The role of the individual on the surgical team, previous knowledge about NTS for surgery and NOTSS-VRC, and details of any prior training were collected. Respondents’ perceptions of the importance of constructs of situation awareness, decision making, leadership, communication and teamwork in the Nigerian context, and their perception of the single most important NTS for personal and team improvement were identified. The survey also identified interest in formal training in NTS, the perceived benefits of NTS. In addition, the survey collected responses on the ideal duration and format for a NTS training program (in person versus online versus blended). A free text section collected hindrances and enabling factors for participating in NTS training.

Names, demographic information, and institutional affiliation were not collected. No personal information was collected or stored. Information was collected using a restricted Google form, and unauthorized access was prevented by limiting editing rights to three investigators. Respondents were able to review and change their answers using a back button. Access to collected data was only permitted on password-protected computer devices. The survey was developed through an iterative process, and the usability and technical functionality of the electronic questionnaire was pre-tested before dissemination. The open survey was not advertised online but was disseminated to surgical, obstetrics, anaesthesia, and perioperative nursing leads at target facilities. The survey was limited to clinically active participants. Initial contact with potential participants was made on WhatsApp, and the forms required web-based data entry. No cookies, IP address check, or automated log file analysis was performed; however, data were cleaned manually and examined for double entries and other inconsistencies including submissions with atypical timestamps.

Surveys were administered through an electronic, web-based, single-page Google form with 19 questionnaire items, and responses were automatically captured. No incentives were provided to any participants. Data were collected from August 9 to October 6, 2021. Items and questionnaires were not randomized or alternated. A post-submission completeness check was carried out, finding that 6 respondents had incomplete entries. The response rate was 95.7% ( n = 68; N = 71); and the completion rate (the number of people submitting the last questionnaire page, divided by the number of people who agreed to participate or submitted the first survey page) was also 95.7% ( n = 68; N = 71). Any questionnaires with less than 50% completion, or with missing demographics ( n = 4) were excluded from analysis. Questionnaire items were not weighted, and propensity scores were not applied to adjust for any sample. Analysis was carried out in R software version 4.1.0 [ 17 ] using proportions and Fisher’s exact test. We analysed free text written responses to identify barriers and enhancers to NTS training in the context and generated themes using the qualitative constant comparative method as described by Glaser [ 18 ]. Responses were quantised by theme and presented by frequency and percentage alongside quotes of sample phrases. We used group open coding involving one investigator and a research assistant (BA and PK) and resolved disagreements by discussion. Qualitative analysis was carried out using a grounded theory qualitative approach and a constructivist research paradigm and a convergent (parallel) design [ 19 ]. The free text data were analysed using topic detection/categorisation technique which employs grouping or bucketing of similar themes relevant for the project [ 19 ]. No sub-categories were identified. Inductive qualitative analysis was carried out [ 18 ]. For the two open-ended questions from the survey, we categorized the text into a number of similar themes in an inductive manner [ 18 , 19 ].

There was a total of 67 respondents, which included 17 anaesthesia providers (25.4%), 21 perioperative nurses (31.3%), and 29 surgeons and surgeons-in-training (43.3%).

Overall, there was poor awareness of NTS across all specialties (Table 1 ), with only 32 of 67 (47.8%) having heard of NTS use in surgery. This shortfall in awareness was most evident amongst the anaesthesia providers with only 6 of 17 (35.3%) having previously heard of NTS, compared with 13 of 29 (44.8%) of surgical providers, and 13 of 21 (61.9%) of perioperative nursing staff. Similarly, awareness of NOTSS-VRC training was low with only 14 (21.2%) having previously heard of any NTS course adapted for variable resource contexts. This was particularly true of surgeons/surgeons-in-training relative to other professions ( p = 0.022), as only 2 (6.9%) had prior knowledge of the course. Only 6 respondents (9.1%), none of whom were surgeons, had previously attended a NTS training program ( p = 0.031). The NTS training courses that respondents specified that they had attended previously were not purely NTS training, as they were exclusively local hospital or university-based training sessions rather than internationally recognised training courses. One respondent identified a ‘handling and maintenance of minimally invasive instruments’ training course as containing NTS.

When asked to rate each of the components of NTS in terms of importance, all categories were rated predominantly as ‘very important’ (86.6–91.0%). None of the NTS categories were rated as ‘not important’ by any of the respondents. In ranking the four categories (Table 2 ), overall, most respondents (38, 56.7%) ranked ‘communication and teamwork’ as the one they would most personally like to learn about and ‘situational awareness’ as the least. This held true across specialties with no statistically significant difference between groups’ ranking of the categories. In addition, respondents perceived that ‘communication and teamwork’ were most needed for interprofessional team improvement in their context. Deviating from other surgeons and anaesthesia providers, nursing staff ranked decision making as less important than leadership; however, this was not statistically significant (Fisher’s exact p -value = 0.055).

There was an overwhelming positive interest in receiving NTS training in the future with 64 respondents (95.5%) expressing a desire to attend training. Their primary motivation was that NTS training would improve patient safety (66; 98.5%). Table 3 shows the preferred duration and format for NTS training.

The most common thematic barriers to respondents attending NTS training in the future included time conflicts (31, 46.3%), and cost barriers (14, 20.9%). Lack of access to training (10, 14.9%) and an unsupportive work environment (9, 13.4%) such as hierarchical dynamics and work-related psychological stress were also identified as key barriers (Table 4 ). Seventeen respondents (25.4%) identified no barriers to attending future NTS training. The most common enabling factor for attending future NTS training was the desire to improve patient safety (34, 50.7%). The desire for self-improvement (18, 26.9%) and the desire for an improved work environment (10, 14.9%) were also identified as key enabling factors. Five respondents (7.5%) could not highlight any factors which would motivate them to attend a future NTS training course.

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 ].

Limitations

Although this work sampled surgical service providers at secondary and tertiary level facilities, some surgical services (circumcision, debridement, initial open fracture care, incision, and drainage of abscesses etc.), are also being provided at primary level in Nigeria and other parts of sub-Saharan Africa and were not included in this survey. In addition, this survey was purposively limited to North-Central Nigeria due to maximize resources and connections. It could have been distributed to a broader population for more representative national data. Further studies involving providers at this level may provide a more holistic understanding of motivations for NTS training. Secondly, challenges of internet access in an LMIC like Nigeria might bias results, as only surgical providers, anaesthesiologists, and nurses with internet access or internet enabled devices could have responded. The likelihood of exposure to NTS may be higher among those with internet enabled devices, considering the increase in online education following the COVID-19 pandemic. Future research should consider hybrid online and interviewer-administered paper surveys to ensure a more representative sample.

Surgical teams in North-Central Nigeria are highly motivated for NTS training. Multi-disciplinary and inter professional teams consisting of perioperative nurses, anaesthesia providers, and surgeons believe that NTS skill development can improve patient safety, team dynamics, and personal performance. In the context of Nigeria, implementation should emphasize communication and teamwork to address the tensions and interprofessional rivalry noted in the local work culture. A hybrid, low-cost approach to training (combining online and in-person components) is preferred by respondents. Optimizing the work environment and ensuring that hospital and theatre leadership teams buy into the programs and champion NTS training are key to successful NOTSS-VRC training in this context. The way forward for NTS training in North-Central Nigeria is hybrid, low cost, inter professional training with an emphasis on teamwork and communication for improved patient outcomes and surgical safety.

Availability of data and materials

The dataset used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Interprofessional education

Non-technical skills

Non-Technical Skills for Surgeons

Non-Technical Skills for Surgery in Variable Resource Context

Checklist for Reporting Results of Internet E-Surveys

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Alayande BT, Isichei M, Adejumo AA, Wina FM, Forbes CW, KingPriest PT, Agbo CA, Bekele A, Riviello R. Non-technical skills training for Nigerian surgical teams: which way forward? J Am Coll Surg. 2022;235(5):S226–7. https://doi.org/10.1097/01.XCS.0000894776.72384.9a .

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Acknowledgements

Steven Yule, Robert Riviello, and Mercy Isichei are co-senior authors, with equivalent contributions.

The Non-technical Skills for Surgery Nigeria Group

Barnabas Tobi Alayande 1,2,3,4

Callum Forbes 1,3

Paul KingPriest 4

Adeyinka Adejumo 5

Felix Wina 7

Christian Agbo Agbo 8

Bamidele Omolabake 8

Bashiru O Ismaila 2

Augustine Sule 2

Egide Abahuje 10,11

Robert Riviello 1,3,6,12

Mercy Isichei 2,14

Tosin Abah 4

Akims Shattah 2

Linus Hapiyati Homoweto 4

John Onyeji 15

Joseph Okoko 16

Joshua Sule 16

1 Center for Equity in Global Surgery, University of Global Health Equity, Rwanda

2 Department of Surgery, Jos University Teaching Hospital, Nigeria

3 Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, United States of America

4 Surgical Equity Research Hub, Jos, Nigeria

5 Federal Medical Centre, Keffi, Nasarawa State, Nigeria

6 Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America

7 Department of Surgery, Bingham University Teaching Hospital, Jos, Nigeria

8 Department of Surgery, Benue State University Teaching Hospital, Markudi, Nigeria

9 Department of Clinical Surgery, The University of Edinburgh, Edinburgh, United Kingdom

10 University of Rwanda, Kigali, Rwanda

11 Department of Surgery, Northwestern University, Evanston, Illinois, United States of America

12 Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America

13 The Faith Alive Foundation, Jos, Nigeria

14 Department of Obstetrics and Gynaecology, Bingham University Teaching Hospital, Jos, Nigeria

15 Garki Specialist Hospital, Abuja, Nigeria

16 Oasis Medical Center, Jos, Nigeria

Barnabas Alayande was funded for this research by the Association for Academic Surgery/Association for Academic Surgery Foundation Global Surgery Research Fellowship Award 2021. AAS had no direct involvement in the design of the study, data collection, analysis, and interpretation of data, and in writing the manuscript.

Author information

Steven Yule, Robert Riviello and Mercy Isichei contributed equally to this work.

Authors and Affiliations

Center for Equity in Global Surgery, University of Global Health Equity, Kigali, Rwanda

Barnabas Tobi Alayande, Callum Forbes, Abebe Bekele & Robert Riviello

Department of Surgery, Jos University Teaching Hospital, Jos, Nigeria

Barnabas Tobi Alayande, Bashiru O Ismaila, Augustine Sule & Mercy Isichei

Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, United States of America

Barnabas Tobi Alayande, Callum Forbes & Robert Riviello

Surgical Equity Research Hub, Jos, Nigeria

Barnabas Tobi Alayande & Paul Kingpriest

Federal Medical Centre, Keffi, Nasarawa State, Nigeria

Adeyinka Adejumo

Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA, United States of America

Wendy Williams & Robert Riviello

Department of Surgery, Bingham University Teaching Hospital, Jos, Nigeria

Department of Surgery, Benue State University Teaching Hospital, Markudi, Nigeria

Christian Agbo Agbo & Bamidele Omolabake

Department of Clinical Surgery, The University of Edinburgh, Edinburgh, UK

Fiona Kerray & Steven Yule

University of Rwanda, Kigali, Rwanda

Egide Abahuje

Department of Surgery, Northwestern University, Evanston, Ilinois, United States of America

Department of Surgery, Brigham and Women’s Hospital, Boston, MA, United States of America

Jamie M. Robertson & Robert Riviello

The Faith Alive Foundation, Jos, Nigeria

Mercy Isichei

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Barnabas Tobi Alayande
, Callum Forbes
, Paul Kingpriest
, Adeyinka Adejumo
, Bamidele Omolabake
, Bashiru O Ismaila
, Augustine Sule
, Egide Abahuje
, Robert Riviello
, Mercy Isichei
, Tosin Abah
, Akims Shattah
, Linus Hapiyati Homoweto
, John Onyeji
, Joseph Okoko
& Joshua Sule

Contributions

B.T. made substantial contributions to study conceptualization, design of the survey, acquisition, analysis, and interpretation of data, and contributed to drafting and reviewing the work. C.F., and P.K. contributed to the acquisition, analysis, and interpretation of data contributed substantially to the original draft and substantively revised it. The Non-technical Skills for Surgery Nigeria Group was involved in the acquisition, interpretation of data, and substantively revising the work. A.A., S.F.W., C.A.A., B.O.I., B.O. acquired and interpreted data and substantially revised the draft. W.W., F.K., A.S., E.A., J.M.R. made substantial contributions to interpretation of data, and substantially revised the manuscript. A.B., S.Y., R.R., and M.I. made substantial contributions to survey conceptualization, design of the work, validation, supervising the survey and substantively revising the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Barnabas Tobi Alayande .

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The authors declare no competing interests.

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Alayande, B.T., Forbes, C., Kingpriest, P. et al. Non-technical skills training for Nigerian interprofessional surgical teams: a cross-sectional survey. BMC Med Educ 24 , 547 (2024). https://doi.org/10.1186/s12909-024-05550-8

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Non-technical skills training for Nigerian interprofessional surgical teams: a cross-sectional survey

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The Non-technical Skills for Surgery Nigeria Group

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