This study found that the anaesthetic theatre educational environment was perceived as more positive than negative, but with room for improvement. No other South African study evaluating the educational environment quantitatively could be identified.
A qualitative study (25) analysing registrars’ experience of their training concluded that overall the University of the Witwatersrand (Wits) Department of Anaesthesiology was a positive place in which to learn, similar to the findings of this study.
Three international studies that used the ATEEM instrument in the United Kingdom (UK) (16), which is a developed country, and in Pakistan (24) and Iran (29), which are developing countries, were used to discuss the findings of this study. Only the public sector scores of the Pakistani study (24) were used. To make comparisons more accurate, the mean total ATEEM score in this section was calculated after removing item 41, this study’s adaptation of the ATEEM.
The mean total ATEEM score of this study after removal of the adaptation was 114 out of 160 and this score was comparable to the studies in the UK (16), Iran (29) and the public sector of Pakistan (24) with scores of 117, 114 and 109 respectively. The mean total score for all three studies fell into the same category of more positive than negative, but with room for improvement.
When comparing the scores of the domains of the ATEEM between this study and the studies in Iran (29) and Pakistan (24), all three studies had the same highest and lowest scoring domains. Autonomy was the highest scoring domain, while workload, supervision and support was the lowest scoring domain. This illustrates that anaesthetic trainees in developing countries encounter similar factors that promote or inhibit a conducive anaesthetic theatre educational environment.
The domains of autonomy and learning opportunities and orientation to learning of this study scored higher than in the three international studies (16, 24, 29). The possible reason for the higher scoring of the autonomy domain is the level of responsibility given to training doctors in the South African health system and the accountability for the care given to patients (30). With regard to the learning opportunities and orientation to learning domain, the patient load with varieties of pathology allows for workplace-based learning and the opportunity for exposure to a large number and variety of practical procedures (31).
The workload, supervision and support domain of this study scored lower than the three international studies (16, 24, 29). The possible reasons for this domain scoring lower are the increased patient loads and the staff shortages in the South African public hospitals (32).
Both this study, the Pakistani study (24) and the Iranian study (29) found no statistically significant difference in the scores based on the sex of the respondents. The study conducted in the UK did not analyse differences in scores between male and female respondents. The overall educational environment is therefore similarly experienced by both male and female respondents.
Similar to this study, the study conducted in the UK (16) found differences in scores between the different years of registrar training. This study, as well as the UK study, found a drop in the scores between the first and second registrar training years. In both studies, the second year of registrar training scored the lowest when compared to the first, third and fourth years. In contrast to this study, there was a significant improvement in scores from respondents in their third year, with the third year of registrar training scoring the highest in the UK study. In this study, the scores between the second and third years were similar and a significant improvement was seen from third- to fourth-year scores, resulting in the fourth year of registrar training scoring the highest. No reasons were provided for these possible differences in scores observed in the UK study.
The reasons for these differences in this study could be attributed to a few possible reasons based on anecdotal evidence. Firstly, registrars in their first year receive more direct supervision and support from consultants, who are often more lenient with registrars starting their training. Registrars starting their training are often paired with more senior registrars, providing them with more support and teaching in the theatre environment. Final-year registrars are also given more attention and teaching as they are being prepared for their examinations. Secondly, the second and third years of training are stressful and demanding. It is the start of the specialist rotations such as cardiothoracic and neurovascular, there is a steep learning curve and increase in responsibilities, and the bulk of the compulsory research component of the training programme takes place during these years.
The three lowest scoring questions in this study were: “There is an informative anaesthetic trainee handbook”, “Whenever I should participate in formal educational programmes, I get relief from theatre duties” and “My workload in the hospital is manageable”. Similarly, the study conducted by Cuthbert (25) concluded that some of the major shortcomings of the current learning environment according to registrars was the lack of relief from theatre duties for formal teaching and the workload in the hospitals. There is no informative trainee handbook or equivalent document to guide the training programme of anaesthesiology registrars at Wits. Therefore, registrars resort to compiling their own document.
Sexual, gender and racial discrimination in the workplace are issues that have been receiving increasing attention. This study found that 20% of respondents agreed to the presence of sexual or gender discrimination and 21% agreed to the presence of racial discrimination. Of the respondents, 54% were neutral with regard to the presence of sexual, gender and racial discrimination. Although most respondents in this study remained neutral or disagreed with regard to the sexual, gender and racial discrimination questions, these are still important social issues that need to be continuously addressed. In the study by Cuthbert (25), very few narratives specific to sexual, gender or racial discrimination were offered and, according to the author, this lack of commentary suggested that sexual, gender and racial discrimination were sensitive but less pertinent issues that require further investigation.
The possible limitations of this study are that this study was contextual to the Department of Anaesthesiology at Wits, and therefore the results of the study may not be generalisable to anaesthesiology departments at other institutions. Furthermore, the ATEEM instrument is unidimensional as it assesses only the registrars’ perception of the educational environment and does not assess the perception of the educational environment by educators and other stakeholders.